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10   years    aF^e^   hreahmenh_  page    264, 


OETHOP^DIA 


A   PRACTICAL   TREATISE 


ABERRATIONS    OF    THE    HUMAN    FORM. 


A    SECOND  EDITION, 

MUCH   ENLARGED,    WITH    ADDITIONAL   ENGRAVINGS  AND 

SEVERAL   COLORED  LITHOGRAPHS. 


JAMES   KNIGHT,  M.D., 


Member    of    the    Medico-Chirukgicai.    Faculty    of    Maryland,    the    District    Medical 

Society    of    Ohio,    the    Coukty    Medical    Society    and    the    Academy   of 

Medicine   of   New    York  ;     and  Surgeon-in-Chief  to   the    New 

York  Society  for  the  Relief  of  the    Buptcbed 

AND     Crippled,     etc.,    etc. 


NEW  YOEK: 

J.   II.   VAIL   &c   CO., 

21  AsTOR  Place. 

1884. 


)  f  f4 


Entered  according  to  Act  of  Congress,  in  the  year  1884, 

By   JAMES  ^KNIGHT,    M.  D., 

In  the  oflBce  of  the  Librarian  of  Congress,  at  Washington. 


a 


CONTENTS. 


CHAP.  PAGE. 

I.  Remarics  on  Defective  Physical  Formation 9 

II,  Impairment  of  Tissues  Resulting  in  Contortion 39 

III.  General  Remarks  on  the  Treatment  of  Talipes C2 

IV.  Infantile  Paralysis 91 

V.  Electricity  as  a  Therapeutic  Agent  in  the  Treatment  of  Par- 
alysis     120 

VI.  Contraction  of  the  Hands,  Fingers  and  Toes  ]  68 

VII.  Lateral  Curvature  of  the  Spine — Torticollis    181 

VIII.  Rachitis 197 

IX.  Hernia —  Procidentia      Uteri  —  Ectropion     Vesicae  —  Relaxed 

Abdomen 211 

X.  Varicose  Veins  —  Burs^e  —  Ganglion 248 

XL  Etiology  of  Constitutional  Dyscrasia 261 

XII.  Pathological  Consideration  of  Diseases  of  the  Joints 278 

XIII.  Advancing  Diseases  of  the  Bones — Necrosis 314 

XIV.  Tonics,  and  their  Effect  upon  the  System 359 


PLATES. 

No.  I.  A  Case  of  Extensive  Ulceration  after  Draining  Sinuses  from  Chronic 

Synovitis  of  tlie  Knee. — Frontispiece. 
No.  II.  Head  of  Tliigli  Bone,  Diseased  Bisection  of  Normal  Form. — Page  265. 
No.  III.  Margin  of  the  Acetabulum,  Presenting  Ulceration — Head  and  Neck  of 

Thigh  Bone  Diseased. — Page  266. 
No.  IV.  Bisections  of  Diseased  and  Sound  Thigh  Bones  of  same  Case. — Page  271. 
No.  V.  Spinal  Caries  Resulting  in  Paraplegia. — Page  273. 


EI^GEAYIIl^GS. 


MO.  PAGE. 

1.  Marked  Case  of  Arrest  and  Deficient  Development 15 

2.  "         "              "        "         "                   "           after  treatment 17 

3.  A  Case  ot  Deficient  Development  of  the  Hands  and  Feet 19 

i.          "         Congenital  Angular  Deformity  of  Tibia  and  Fibula 20 

5.          "               '*               "                "               "                 "  after  treatm't  21 

■6.         "         Deep  Cincture  of  the  Leg  from  a  Constricting  Band 22 

7.  "        Cinctures  of  both  Legs  from  Constricting  Bands 23 

8.  "         Congenital  Luxation  of  the  Hips 26 

9.  Normal  Conformation  of  the  Foot 42 

10.  Formation  of  the  Arch  at  the  inner  side  of  the  Foot 44 

11.  "              "        "        "       outer   "        "        "     44 

12.  Outer  Surface  of  the  Arch  more  distinctly  shown 44 

13.  Skeleton  of  the  Foot    46 

14.  "         "          "    in  Talipes  Varus 46 

15.  Congenital  Talipes  Varus  before  Walking 47 

16.  "            «'            «'          "            "          47 

17.  "            "            "          "            "        more  marked 47 

ig             cc            (<            i(          (<            <(            <i         li         _  _. 47 

19.  Talipes  Valgus 47 

•20.         "            "         47 

21.  "     Equinus 48 

22.  "             "     48 

23.  "    Calcaneus 48 


Vi  ENQRAVINQa. 

NO.  PAGE. 

24.  Position  of  Tendo-Achillis  in  Talipes  Varus 50 

25.  ' '  the  Anterior  Tendons  in  Talipes  Varus 50 

26.  Talipes  Varus  from  Paralysis 51 

27.  Deformity  of  the  Foot,  the  Result  of  Compression 51 

28.  Tenotomy  Knives 61 

29.  Adams'  Modified  "  Scai-pa  Shoe." , 6& 

30.  Case  of  Talipes  Equinus 63 

31.  Author's  Modification  of  the  "  Scarpa  Shoe  " 66 

32.  Springs  for  the  Treatment  of  Talipes  Valgus  (first  stage) 74 

33.  Apparatus   "  "  "  "       (extreme  cases) 75 

34.  Method  of  Application  of  the  modified  "  Scarpa  Shoe  " 76 

35.  "  "  "  "  "  for  Elevation  of 

the  instep 76 

36.  Talipes  Calcaneo- Valgus 77 

37.  Shoe  for  the  Treatment  of  Talipes  Calcaneo-Valgus 77 

38.  Position  of  the  Foot  in  Talipes  Equinus 78 

39.  Extreme  Case  of  Talipes  Equinus 79' 

40.  "  "  "  "  79 

41 .  Apparatus  for  Elongating  the  Plantar  Aponeurosis  {in  situ) 81 

42.  "  "  "  "  "  81 

43.  "  "    the  Treatment  of  Talipes  Equinus 83- 

44.  "  "  "  "  "        applied 83 

45.  Position  of  the  Foot  in  Talipes  Calcaneus  86 

46.  "  "  "  "  "  86 

47.  Tahpes  Calcaneus  with  Marked  Caries  of  the  Bones 87 

48.  Apparatus  for  the  Treatment  of  Congenital  Talipes  Calcaneus 8& 

49.  «'  '«  "  of  Non-Congenital       "  "  8& 

50.  Improved  Apparatus  for  the  Treatment  of  Talipes  Valgus 90' 

51.  "  "  "  "  "  "        applied 90- 

52.  Apparatus  for  the  Treatment  of  Paralytic  Cases 102 

53.  '«  "  "  "  "        back  view 103^ 

54.  <«  ««  ««  Cases  with  Relaxation  of  Hip-Joint  . .  103. 

55.  Shoe  for  Relief  of  Tendency  to  Talipes  Calcaneus 104 

56.  Shoe  applied  after  Division  of  the  Plantar  Fascia 104 

57.  Posterior  Genu  Flexum 112 

58.  Apparatus  for  Treatment  of  Posterior  Genu  Flexum lia 

59.  Extension  Frame 114 

60.  Apparatus  for  the  Treatment  of  Dropped  Hand. 115> 

61.  Machine  for  Accumulating  Static  Electricity 116 

62.  Improved  Holtz  Static  Electrical  Induction  Machine US 


Engra  vings.  vii 

NO.  PAGE-; 

63.  Portable  Electro-Magnetic  Machine 156 

64.  Galvanic  Battery 158 

65.  Cabinet  Regulator  and  Batteries 160 

66.  Bartlett's  Regulator  161 

67.  Galvano-Caustic  Battery 163 

68.  Case  of  Galvano-Caustic  Electrodes 164 

69.  Retentive  Apparatus  after  Operation    for  Dupuytren's  Contraction  of 

the  Fingers 173 

70.  Dr.  Abbe's  Case  of  Dupuytren's  Contraction  of  the  Fingers  (left  hand) . .  174 

71.  "  "                  «                    "                            '«      (right  hand).  174 

72.  Apparatus  for  Contortion  of  the  Toes 175 

73.  "                      "                        "     175 

74.  Second  Stage  of  Lateral  Curvature  of  the  Spine 187 

75.  "            "                "              "            "           " 187 

76.  Lateral  Curvature  of  Spine  with  Four  Curves 188 

77.  Parallel  Bars  for  Exercising 189 

78.  Apparatus  for  the  Treatment  of  the  First  Stage  of  Lateral  Curvature. .  189 

79.  Seat  of  a  Chair  Adjusted  for  Cases  of  Lateral  Curvature 191 

80.  Spinal  Support  for  Advanced  Cases  of  Lateral  Curvature 192 

81.  Spinal  Brace  with  Head  Spring  Attached 196 

82.  "  Pigeon  Breast"  Deformity  of  the  Chest 202 

83.  Truss  for  Treatment  of  "  Pigeon  Breast " 203 

84.  Deformity  of  the  Limbs  in  Genu  Extrorsum 205 

85.  Apparatus  for  the  Treatment  of  Genu  Extrorsum   207 

86.  "            "             "                  "               "        applied 207 

87.  "            "              "               Posterior  Curvature  of  the  Tibia 207 

88.  Deformity  of  the  Limbs  in  Genu  Valgum 208 

89.  Apparatus  for  the  Treatment  of  Genu  Valgum 209 

90.  "              "              "                  "          "          applied 210 

91.  Single  and  Double  Child's  Truss 233 

92.  Single  Truss  applied  for  Inguinal  Hernia 235 

93.  Double     "          "        "    Femoral      "      235 

94.  Double  Inguinal  Truss  applied 235 

95.  Belt  applied  for  Umbilical  Hernia 236 

96.  Belt  for  Umbilical  Hernia 236 

97.  Supporting  Apparatus  for  Irreducible  Hernia 237 

98.  Abdominal  Belt  with  Perineal  Elevator,  applied 242 

99.  "            "                  "                " 242 

100.  Cross  Strap  and  Triangular  Perineal  Elevator 242 

101.  Case  of  Ectropion  Vesicfe 243 


viii  Engravings. 

NO.  PAGE. 

102.  Appliances  for  Compression  in  Varicose  Veins,  etc 253 

103.  Measurements  for  Stockings,  etc 253 

104.  "  "  "     253 

105.  Case  of  Extensive  Ulceration  after  Chronic  Synovitis  of  the  Knee 264 

106.  Change  in  Contour  of  Nates  in  First  Stage  of  Hip  Disease 285 

107.  Position  of  the  Afiected  Limb  in  the  Second  Siage  of  Hip  Disease 288 

108.  Contour  of  the  Nates  "  "  "  "  290 

109.  Application  of  the  Roller  in  Hip  Disease 298 

110.  Dislocation  of  the  Head  of  the  Femur  in  Hip  Disease 301 

111.  Extension  Apparatus  in  Hip  Disease  applied 301 

112.  "  "  "  302 

113.  Apparatus  for  Straightening  the  Limb  in  advanced  Hip  Disease 303 

114.  Cork  Wedge  in  Shoe  to  Lengthen  the  Limb -. 304 

115.  Appliance  to  be  used  where  Toes  have  been  Amputated  304 

116.  Knee  Brace  for  the  Treatment  of  Synovitis 320 

117.  "        "  "  "  "  affording  more   extensive 

support 321 

118.  Knee  Brace  for  the  Treatment  of  Synovitis,  affording  more  extensive 

support,  applied  322 

119.  Simple  Knee  Brace,  applied 322 

120.  Angular  Deformity  of  the  Knee 323 

121.  "  "  "       Elbow 323 

122.  Gonyometer 325 

123.  Subluxation  of  the  Tibia  in  Syno^•itis  of  the  Knee 327 

124.  "  "  "  "  "         "  with  apparatus  applied.  327 

125.  Locomotive  Cantering  Horse 332 

126.  Swing  for  Exercise  in  Paraplegia,  etc 333 

127.  Incurvation  in  Incipient  Spinal  Disease 337 

128.  Caries  of  the  Mid-dorsel  Vertebrae 338 

129.  "  "       Lumbar  "  338 

130.  Lateral  Curvature  in  Caries  of  the  Spine 339 

131.  Knuckle-like  Projection  in  Cervical  Caries 343 

132.  More  marked  Deformity  "  "        344 

133.  Brace  for  the  Treatment  of  Caries  of  the  Spine   348 

134.  <<        "  "  "  "  "     with  Pad  for  the  Hip 

attached 349 

135.  Spinal  Brace  with  Head-Spring  attached 349 


ORTHOPiEDlA. 


INTRODUCTORY   REMARKS. 


The  attainment  of  practical  information  on  the  subject  of 
aberrations  of  the  human  form,  and  the  tendency  thereto,  is,  at 
the  present  day,  considered  by  the  medical  profession,  both 
at  home  and  abroad,  to  be  one  of  the  essential  qualifications  of  a 
general  practitioner.  If  he  does  not  assume  the  treatment  of  this 
class  of  ailments,  he  should,  at  least,  possess  such  information  as 
would  enable  him  to  diagnosticate  in  its  incipiency  the  patholog- 
ical condition  that  would  tend  to  deformity  of  the  person,  and 
thus  refer  the  patient  to  an  experienced  orthopaedic  surgeon.  To 
the  aflELicted,  this  is  of  inestimable  importance,  impressing  them 
with  confidence  in  treatment,  as  well  as  in  the  high  order  of  the 
attainments  of  their  medical  adviser. 

This  knowledge  is  most  difficult  to  attain  in  an  ordinary  gen- 
eral practice,  the  patients  being  so  sparsely  distributed,  and  insti- 
tutions for  their  treatment  so  limited.  As  a  means  of  imparting 
information  upon  this  important  branch  of  medical  education,  a 
careful  revision  of  a  series  of  years  of  successful  practice  is  pre- 
sented, with  a  desire  that  it  may  be  considered,  in  a  limited 
degree,  as  a  favorable  succedaneum  to  that  of  a  more  practical 
acquirement,  and  with  the  conviction  that  it  is  a  duty  due  to  each 
other  from  all  associates  in  a  liberal  profession,  to  impart  to  the 
best  of  their  ability  snch  supposed  acquirement  of  knowledge 
as  long-continued  labor,  under  favorable  circumstances,  would 
yield  to  diligent  inquiry. 

Our  public  and  private  practice  has  been  most  largely  devoted 
in  professional  service  to  the  relief  of  crippled  children.  The 
first  effort  at  devising  surgico-mechanical  appliances  was  made  at 


2  OrTHOPjEBIA. 

tlie  dispensary,  and  for  the  relief  of  reducible  hernia,  with  a  view 
to  obviate  much  of  the  suffering  inflicted  by  the  ordinary  trusses 
then  in  use.  The  result  was  a  very  decided  success,  and  an  incen- 
tive to  the  construction  of  appliances  for  the  restoration  of  im- 
paired powers  of  locomotion  in  children  laboring  under  deformities 
both  congenital  and  the  sequelae  of  infantile  paralysis.  Other  de- 
formities, resulting  from  constitutional  impairment,  led  to  a  careful 
study  of  the  pathological  conditions  tending  to  the  various  phases 
of  deformity  of  body  and  limbs,  such  as  caries  of  the  spine,  termi- 
nating in  spinal  or  psoas  abscess,  morbus  coxarius  in  its  several 
stages,  involving  the  destruction  of  the  joint  and  often  loss  of 
life,  and  synovitic  invasion  of  the  joints.  These  latter  ailments 
were  carefully  considered,  and  a  careful  regime  with  proper 
sanitary  regulations  and  conditions  were  found  to  be  the  primary 
requisites  of  a  proper  treatment.  Such  conditions,  we  concluded, 
were  only  attainable  in  the  highest  degree,  in  a  hospital  of 
proper  construction.  With  this  impression  we  introduced  the 
initiatory  efforts  in  our  own  dwelling  —  tending  to  success  far 
exceeding  expectation- — resulting  in  the  organization  of  a  society, 
which  was  favored  with  most  liberal  donations,  enabling  us  to 
organize  at  our  discretion  a  Hospital  for  the  Relief  of  the  Rup- 
tured and  Crippled.  The  indigent  were  received  free  of  charge, 
and  the  payments  from  others  contributed  to  the  support  of  the 
house.  Upwards  of  5,000  in-patients  have  received  treatment 
during  the  ten  years. 

Other  ailments  incidental  to,  and  requiring  mechanical  support, 
as  pi'ocidentia  uteri,  varicose  veins  and  consequent  ulceration, 
have  also  received  careful  study,  and  the  treatment,  with  suitable 
appliances,  represented  in  this  work  by  wood  engravings,  has 
been  attended  with  much  success,  these  appliances  being  largely 
supplied  to  out-door  patients. 

The  treatment  of  deformity  has  been  one  of  the  greatest 
difficulties  encountered  by  the  general  practitioner  in  medicine, 
even  to  the  abandoning  of  all  attempts  at  efforts  to  redress  cur- 
able deformities  in  children,  especially  that  of  clubfoot.  The 
seeming  impossibility  of  treating  deformities  by  regular  practi- 
tioners in  medicine,  even  in  this  advanced  state  of  medical  science, 
has  caused  orthopaedic  surgery  to  be  assumed  by  mere  adven- 


Introductory  Remarks.  3 

turers,  destitute  of  medical  knowledge,  to  their  great  pecuniary 
advantage  and  the  discredit  of  the  medical  profession. 

There  is  another  unfavorable  circumstance,  much  to  be  regret- 
ted, as  it  seriously  discourages  those  competent  to  attain  a  knowl- 
edge of  orthopaedic  surgery.  It  is  in  being  deceived  by  the 
exaggerated  laudations  of  inventions  of  no  particular  merit, 
devised  by  practitioners  in  medicine,  and  some  of  great  notoriety. 
All  appliances,  however  skilfully  constructed,  are  only  auxiliary 
means  in  the  treatment  of  deformity,  and  may  be  used  to  greater 
advantage  by  the  inventor  than  by  even  those  quite  as  familiar 
with  the  treatment  of  these  ailments ;  each  having  peculiarly 
devised  or  modified  apparatus  for  the  treatment  of  their  patients. 
To  give  promise  of  success  in  the  treatment  of  deformity,  it  is  a 
most  essential  acquirement  to  the  student,  to  have  sufficient  practi- 
cal knowledge  to  make  a  correct  diagnosis  of  the  case,  then  to  care- 
fully consider  the  indications  that  present  themselves,  and  rely  upon 
his  own  judgment  as  to  the  means  that  will  most  readily  apply  to 
the  redressing  of  the  abnormal  condition.  Even  then  he  may  fail 
in  his  first  attempts  in  treatment,  but  it  will  not  be  so  discourag- 
ing, inasmuch  as  this  has  been  his  own  device,  tending  necessarily 
to  improvement.  It  would  have  been  discouraging,  however, 
had  he  failed  in  the  treatment  relied  upon  for  some  highly-extol- 
led appliance  —  the  device  of  some  reputable  practitioner,  and 
supposed  to  be  perfect.  The  success  in  treatment  is  the  result 
of  practical  skill,  and  not  wholly  in  the  well-designed  apparatus, 
which  will  only  meet  certain  indications  for  a  time,  and  fail  in 
the  progress  of  treatment.  From  this  fact,  we  became  convinced 
of  the  impossibility  of  attaining  success  in  orthopsedic  practice, 
by  an  entire  reliance  upon  the  devices  of  surgical  appliances, 
however  skilfully  constructed.  All  apparatus  must  be  modified, 
and  the  judgment  of  the  practitioner  exercised,  as  to  the  modifi- 
cations that  may  be  required  from  time  to  time,  as  successful 
progress  is  made  in  the  treatment.  Hence,  the  roller  and  its 
application  claims  important  consideration,  and  practical  skill  in 
making  it  available  in  the  redressing  of  deformity.  Withouc 
knowledge  of  the  application  of  the  roller,  or  what  is  in  some 
cases  of  greater  utility  in  treatment,  perfectly  fitting,  enveloping 
devices  of  woven  fabric  made  to  lace  over  large  abscess  develop- 


4  Orthop^dia. 

mentSj  we  are  without  tiie  most  efficient  means  for  redressing 
deformity,  especially  of  the  feet  and  limbs.     Complicated  appa- 
ratus onl}^  serves  to  confuse  and    embarrass  the    practitioner, 
especially  when  not  devised  by  himself,  as  he  will  construct  or 
modify  to  meet  various  indications  that  are  apparent  in  nearly 
every  recurring  case,  and  which  cannot  be  considered  by  the  prac- 
titioner who  has  constructed  an  apparatus  for  general  use,  a  fair 
sample  of  which  can  be  found  in  the  surgical  instrument  makers' 
shops.     The  various  engravings  of  apparatus  presented  in  this 
work  are  only  intended  to  impress  ideas  in  regard  to  the  con- 
struction of  modified  forms  to  meet  presenting  indications.    Many 
novel  forms  are  introduced  to  meet  the  results  of  existing  anom- 
alies presenting  in  the  treatment  of  deformity,  such  as  have  failed 
to  invite  sufficient  attention,  more  especially  in  the  incipiency  of 
ailments  tending  to  an  increase  of  the  abnormal  condition,  as 
lateral  curvature  of  the  spine,  depressed  arch  of  the  foot  (wliich 
tends  to  valgus),  contracted  toes,  and  many  other  tendencies  to 
contortion  of  parts  of  the  body  and  limbs,  which  a  very  simple 
appliance  would  have  restored  to  normal  form.     These  modified 
appliances  are  the  result  of  the  peculiar  necessities  of  cases  pre- 
sented for  treatment.     In  this  we  have  been  greatly  favored  — 
having  had   the  supervision  of  26,448  patients  within  the  past 
ten  years  in  the  "Hospital  for  the  Relief  of  the  Euptured  and 
Crippled,"    and   previously   a  private  practice  of  thirty   years, 
limited  mainly  to  ailments  treated  of  in  this  work.     During  this 
period  we  have  carefully  studied  the  pathological  condition  of 
each  patient  and  the  result  of  treatment,  availing  ourselves  of 
the    observations   and   inventions    of   eminent    practitioners   in 
this  and   foreign    countries,    though   not   always  in   the  actual 
form   of  the  inventor's  design,  nor  strictly  to  the  letter  as  to 
treatment  —  personal  experience  and  judgment  tending  to  modi- 
fication.    Hence,  the  subject-matter  of  this  work  may  be  con- 
sidered   as   the   varied   and    consolidated   experience   of  many 
practitioners,   modified   to   our  judgment.     Nearly    every  writ- 
ten authority    upon   the   subject  herein  treated  has  been  care- 
fully considered  and  made  applicable  to  our  practice,  however 
much  we   may  claim  as  our  share  of  practical   attainment   in 
the  treatment  of  this  class  of  ailments,  which  we  have  greatly 


Introbuctory  Remarks.  5 

restricted  from  adventurous  treatment  to  that  of  the  expect- 
ant. The  results  have  proved  most  favorable  in  our  practice  — 
seventy-five  per  cent  of  the  ordinary  conditioned  patients  labor- 
ing under  synovitic  disease  having  been  restored  to  self-sustaining 
ability,  the  diseases  having  been  arrested  and  the  limbs  restored 
to  usefulness. 

For  this  success  in  treatment  we  are  greatly  indebted  for  the 
advice  of  that  most  eminent  surgeon,  the  late  Professor  Yalentine 
Mott,  the  first  Consulting  Surgeon  to  the  Hospital  for  the  Eelief 
of  the  Ruptured  and  Crippled,  whose  invaluable  experience  in 
the  treatment  of  these  constitutional  chronic  diseases  was  freely 
imparted ;  and  for  many  years  previous  to  the  opening  of  this 
institution,  was  made  available  to  the  relief  of  vast  numbers  of 
suffering  humanity. 

The  subject-matter  of  this  volume  extends  through  a  large 
range  of  topics,  all  of  which  have  received  careful  consideration, 
as  they  presented  themselves  in  practice.  It  has  also  been  sup- 
plemented by  recent  contributions  from  eminent  living  authors, 
of  the  medical  fraternity,  the  list  of  whom,  only,  would  include 
nearly  all  of  our  compeers  who,  as  specialists,  had  directed  their 
attention  to  the  treatment  of  aberrations  of  the  human  form. 
To  these  authors  we  tender  our  most  grateful  acknowledgments 
for  the  assistance  they  have  afforded  us. 

This  work,  from  absolute  necessity  (our  time  for  literary  labors 
being  necessarily  very  limited),  is  greatly  condensed ;  yet  we 
trust  it  will  be  perfectly  comprehended  by  the  reader.  For 
valuable  assistance  in  the  preparation  of  this  work  for  the  press 
we  are  greatly  indebted  to  Dr.  Yirgil  P.  Gibney,  our  Senior 
Assistant  in  the  Hospital. 


PREFACE   TO    THE   SECOND   EDITION. 


This  second  edition  of  my  treatise  on  Orthopsedia  and  aberra- 
tions of  the  human  form  is  not  to  be  considered  so  much  a  repara- 
tory  of  the  first  edition  as  including  an  addenda  of  useful  informa- 
tion. To  the  reviewers  of  my  first  edition  I  would  beg  to  express  my 
grateful  consideration  of  their  very  favorable  report  of  my  efforts  to 
introduce  subject  matter  worthy  of  presenting  to  the  medical  profes- 
sion. Of  this  character  is  the  entirelj^  new  chapter  that  has  been 
added  on  the  etiology  of  acute  and  chronic  invasions  of  the  joints. 
To  illustrate  more  fully  the  changes  described  as  taking  place  in 
the  morbid  tissues,  new  engravings  and  colored  plates  have  been 
inserted. 

Constitutional  dyscrasia  is  also  made  a  subject  for  consideration 
in  this  chapter,  in  which  my  impressions  as  to  a  predisposing  tendency 
to  the  invasion  of  joints  resulting  in  chronic  synovitis  are  presented. 

Eminent  professional  authority  describe  struma  as  existing  under 
two  conditions,  one  with,  and  the  other  without  tubercle.  The  dis- 
tinctive feature  to  be  observed  is  that  patients  laboring  under  joint 
disease  with  a  tubercular  diathesis  suffer  less  pain  than  those  said 
to  be  of  strumous  character  without  tubercle. 

Struma  without  tubercle  I  consider  to  be  a  scorbutic  diathesis, 
and  I  have  presented  my  views  and  authority  on  this  subject,  which 
I  believe  to  be  a  very  important  one,  inasmuch  as  a  proper  compre- 
hension of  it  enables  us  to  determine  a  prognosis,  as  to  the  result  to 
be  anticipated  from  the  expectant  or  conservative  surgical  treat- 
ment. 

Joint  lesions  in  scorbutic  subjects  I  consider  amenable  to  actual 
cure,  while  similar  invasions  in  cases  of  struma  with  tubercle,  are 
only  held  in  abeyance  and  are  subject  to  amelioration  by  treat- 
ment. The  most  promising  means  of  relief  in  either  case  is 
that  afforded  by  the  so-called  "  conservative  "  or  "  expectant  plan 
of  treatment,"  which  is  not  merely  a  masterly  non-interference  with 


8  Orthop^bia. 

the  progress  of  a  destructive  morbid  jDrocess,  but  consists  in  a  prop- 
erly enforced  hygiene;  careful  medical  attention  to  intercurrent 
disorders  of  the  system;  supporting,  tonic  and  constitutional  treat- 
ment; a  regular  and  nutritious  dietary;  the  treatment  of  abscesses, 
ulcers  and  sinuses;  the  use  of  mechanical  aj)pliances  to  secure  rest 
for  an  invaded  joint,  and  to  prevent  or  correct  the  malposition  of 
the  limbs,  yet  avoiding  every  grave  surgical  interference  in  cases  of 
caries  cJr  necrosis  of  bone,  and  employing  every  means  that  contri- 
butes to  the  strength,  vitality  and  comfort  of  the  patient. 

In  this  careful  enforcement  of  conservative  surgical  treatment  in 
the  Hospital  for  the  "Relief  of  the  Ruj)tured  and  Crippled,  I  am 
favorably  supported  by  such  eminent  authority  as  Bilroth  of  Vienna, 
and  other  European  surgeons,  and  as  Prof.  Frank  H.  Hamilton, 
M.D.,  of  New  York  City,  one  of  the  surgeons  selected  to  participate 
in  the  treatment  of  the  fatally  wounded  President  of  the  United 
States.  This  eminent  gentleman,  m  a  letter  to  the  Board  of  Man- 
agers of  this  Institution,  now  on  record,  states  that  he  is,  after 
twenty  years  of  observation,  in  perfect  accord  with  the  profes- 
sional treatment  of  the  patients  in  the  Hospital  for  the  Relief  of 
the  Euptured  and  Crippled,  and  suggests  that  there  should  be  en- 
graved on  the  walls  over  the  entrance  "  Conservatism." 

For  assistance  involved  in  supervising  the  printing  of  this  second 
edition  of  my  work,  I  am  much  indebted  to  the  valuable  services  of 
my  present  senior  assistant,  H.  J.  Bogardus,  A.M.,  M.D. 


CHAPTER  I. 


REMARKS  ON  DEFECTIVE  PHYSICAL  FORMATION. 

Congenital  aberration  of  the  liuman  form  anciently  attributed  to  mental  and 
physical  impressions  on  the  enciente. —  The  laws  of  Lycurgus  in  relation  to 
malformed  offspring.  —  The  undue  severity  of  these  laws  naturally  prompted 
efforts  for  cure. —  Modern  theories  and  investigations  with  deductions  there- 
from.—  R.  W.  Tamplin's  opinion  as  to  the  cause  of  congenital  deformities  of 
the  feet. —  Unfavorable  position  of  the  feet  in  children  and  adults  results  in 
persistent  deformity. —  Intra-uterine  life,  and  its  susceptibility  to  change  in 
health  and  physical  formation. —  The  dogmas  of  Hippocrates,  Pare,  Petit,  etc., 
in  reference  to  the  causes  of  congenital  deformities. —  The  opinions  of  MM. 
Serres,  Geoffrey  Saint  Hilaire  and  Roux,  compared  with  the  diverse  views  of 
Tiedman  on  the  subject. —  Guerin's  theories  on  the  causes  of  foetal  deformity, 
as  presented  and  illustrated  by  him  before  the  Academy  of  Sciences  at  Paris. 

—  Our  own  professional  experiences  as  to  defective  physical  formation,  illus- 
trated by  the  history  and  diagnosis  of  patients. —  Arrest  of  development  and 
contortion  the  inevitable  result  of  abnormal  nervous  energy,  as  demonstrated 
in  the  histories  of  several  recent  cases. —  Diagnosis  and  treatment  of  the  case 
of  Maggie  K. —  Marked  and  permanent  improvement  after  a  year's  treatment. 

—  Recapitulation  of  facts  deduced  from  this  case. — Extraordinary  instance 
of  uniform  arrest  of  development. —  History  of  patient. —  Cases  of  angular 
bending  of  lower  third  of  tibia  and  fibula,  without  retraction  of  the  muscles. — 
C&se  of  primipara,  band  encircling  right  leg  below  knee. —  Case  of  club-foot, 
with  cinctures  in  limbs. —  Blemishes  ;  difficulty  in  assigning  origin  ;  the  varied 
forms  they  assume. —  Curious  practices  in  horse-breeding. —  Abnormal  marks 
and  appearances  on  newly-born  children,  their  origin. —  COKGENiTAii  Luxa- 
tion.—  Luxation  of  the  hip. —  Knowledge  as  to  treatment  of  this  affliction 
extremely  limited. —  Congenital  luxation  in  the  earlier  periods  of  gestation; 
its  effect  on  the  articulating  cavities. —  Its  protracted  development. —  Peculiar 
symptoms. —  Disease  generally  hereditary  —  Dupuytren's  case  of  an  entire 
family  afflicted  with  congenital  luxation. —  Doubtful  whether  the  cause  is 
arrest  of  development  of  the  cotyloid  cavity  or  simply  muscular  retraction. — 
Ancient  Treatment  of  Deformity. —  Talipes  treated  by  Hippocrates  500 
B.  c,  but  not  again  made  the  subject  of  research  for  1600  years. —  Ambrose 


10  Or  tmopjedia. 

Fare's  Treatise  on  Talipes. —  Construction  of  artificial  limbs  and  surgical 
apparatus  first  described.  —  Hildanus'  extension  apparatus  and  splint. — 
Description  of  an  extension  splint  for  contracted  knee-joints. —  Grlisson's  treat- 
ment of  deformity  by  extension,  a.d.  1651. —  Extension  by  weights  and  cords 
not  novel. —  Method  of  extension  and  counter-extension  by  Scultetus. —  Shoes 
for  the  cure  of  talipes  described  by  Circoeus. — Treatment  of  spinal  curvature 
and  torticollis  by  Isaac  Miucius  and  Heister. —  First  application  of  the  term 
"  Orthopoedia  "  to  deformity  in  children,  by  Mr.  Andrys. —  Establishment  of 
an  institution  for  the  cure  of  talipes  by  Venel  and  Tiphaisne. — Publication  of 
the  results  of  Venel's  treatment  by  Dr.  Ehremann  and  coadjutors. —  Scarpa's 
shoe. —  His  celebrated  monograph  "  Sulle  Piedi  Ferti." — The  application  of 
elastic  force  absolutely  essential  in  all  apparatus  intended  to  overcome  mus- 
cular contraction. —  Ancient  Treatment  of  Spinal  Deformities. —  Treat- 
ment by  suspension  and  lever. —  Park's  treatment  for  cleft  palate. —  Pare's 
metallic  corset  the  earliest  piece  of  mechanism  for  the  relief  of  the  distorted 
spine. —  Le  Vasher's  apparatus  for  the  relief  of  caries  of  the  cervical  vertebrae. 

—  Sheldrake's  apparatus  for  spinal  curvature. — Darwin  an  advocate  of  this 
treatment. —  Surgical  Means  of  Redressing  Deformity. —  Section  of  Tendo- 
Achilles  as  a  method  of  treatment  for  talipes. —  Molinelli's  opposition  thereto. 

—  Thelsemius,  of  Frankfort,  the  first  promulgator  of  the  principle  of  division 
of  tendons  as  a  treatment  for  pedal  deformity. —  Operation  demonstrating  the 
results  of  his  treatment.  —  Experiment  of  Saratorius  in  a  case  of  talipes 
equinus. —  Michaelus,  of  Marburg,  his  successful  treatment  by  partial  sever- 
ance.—  Opinion  of  Benjamin  Bell  thereon. —  Indifi'erence  of  the  practitioners 
of  that  day  to  the  question  or  remedy  of  deformity. —  Subcutaneous  division  of 
muscles  and  tendons. —  John  Hunter's  advocacy  of  the  system. —  Classification 
of  injuries  sustained  by  the  body. —  Delpech's  application  of  Hunter's  principles 
in  medical  practice.  —  Stromeyer's  initiatory  operations  and  discoveries  in 
scientific  tenotomy. —  Duval,  of  Paris,  his  heroic  treatment  of  club-foot  and 
cognate  affections. —  The  new  system  enthusiastically  adopted  by  Dieffenbach. 

—  The  uniform  success  of  the  new  treatment  for  club-foot  on  the  European 
continent. —  Dr.  Detmold  its  most  successful  and  skilful  operator. —  Simple 
reliance  on  the  operation,  without  subsequent  careful  treatment,  not  only 
delusive  and  disappointing  to  the  patient,  but  fatal  as  to  its  ultimate  success. 


From  the  earliest  psycliological  history  of  mankind  to  the  records 
of  the  present  generation,  congenital  aberration  of  the  hnman  form 
has  invited  the  serious  consideration  of  not  only  the  illiterate,  but 
the  wisest  men  of  their  day ;  this  affliction  being  one  of  the  most 
deplorable  that  can  be  conceived  of,  not  only  to  the  victim  himself, 
but  to  the  parents  of  the  unfortunate  malformed,  or  blemished, 
child.  The  subject  was  long  involved  in  obscurity,  and  early  inves- 
tigations resulted  only  in  speculation,  and  probable  surmise,  as  to 


Defective  Physical  Formation.  11 

the  unfavorable  influences  that  should  have  so  impressed  the  enciente. 
Indeed,  it  is  but  recently  that  physiology  has  been  brought  to  bear 
on  foetal  development,  culminating  in  little  more  than  mere  conjec- 
tural and  seemingly  plausible  solutions  of  the  cause  of  these  lament- 
able occurrences. 

The  idea  most "  commonly  entertained,  even  now,  is  that  mental 
and  physical  impressions  of  a  decidedly  pleasurable,  or  alarming, 
character  made  upon  the  enciente  (as  that  of  great  desire,  bodily 
injury,  and  frightful  or  extraordinary  scenes),  are  causes  of  these 
abnormal  conditions  of  development  in  the  foetus.  This  impression 
is  of  the  most  ancient  origin;  as  we  are  informed  in  the  Bible  that, 
1745  years  before  the  Christian  era,  Jacob  was  in  possession  of  infor- 
mation on  this  subject,  and  made  it  available  to  his  advantage. 
There  it  is  stated  that  he,  while  in  charge  of  Laban's  flocks,  experi- 
enced an  irresistible  attachment  for  his  employer's  daughter,  and 
expressed  the  desire  of  making  her  his  wife.  To  this  Laban 
assented,  and  entered  into  a  covenant  with  him,  wherein  it  was 
agreed  that,  after  a  certain  period  of  time,  all  of  the  parti-colored 
cattle  of  the  future  increase  of  his  flocks  should  be  given  to  Jacob, 
who  practiced  the  device  of  placing  jDeeled  rods  in  the  watering 
places  where  the  cattle  came  to  drink.  "And  they  conceived  before 
the  rods,  and  brought  forth  cattle,  ringed,  streaked,  speckled  and 
spotted ; "  *  and  by  the  consequent  increase  he  became  wealthy. 

This  supposed  impression  upon  the  foetus,  an  idea  entertained 
and  strenuously  supported  by  the  ancients,  it  is  most  reasonable  to 
suppose,  influenced  the  Greeks  in  their  submission  to  the  barbarous 
laws  of  Lycurgus,  which  condemned  to  destruction  all  their  deformed 
children,  that  the  supposed  baleful  influence  exercised  upon  the 
enciente  by  the  sight  of  them  might  be  thus  avoided.  Now,  as  then, 
this  idea  obtains  credence  among  parents;  and  the  birth  of  a 
deformed  child  is  considered  as  a  more  sad  affliction  than  the  death 
of  their  most  favored  offspring ;  and,  though  not  openly  acknowl- 
edged, yet  the  impression  is  secretly  entertained,  that  deficiency, 
contortion,  or  blemish  in  an  infant,  has  been  caused  by  some  unfa- 
vorable sight,  or  injury,  or  by  some  extraordinary  desire  not  gratified 
during  gestation,  and  in  this  way  an  injury  inflicted  on  the  foetus. 
Notwithstanding  these  prevalent  notions  as  to  the  cause,  it  is  very 
reasonable  to  suppose  that  treatment  for  deformities  in  children 

■*  Gen.,  cTiap.  xxx,  37tli  to  43d  verses. 


12  OrTHOPjEBIA. 

dates  from  a  very  early  period ;  for  parental  sympathy,  rendered 
even  more  active  by  the  desire  to  save  the  little  unfortunates  from 
the  execution  of  this  obnoxious  law,  would  naturally  prompt  the 
concealment  of  their  condition,  and  induce  efforts  for  their  cure. 

The  more  seemingly  rational  theories  of  the  present  age,  deduced 
from  physiological  investigations,  and  a  consideration  of  the  primary 
formative  process  are : 

1st.  That  of  an  arrestation  of  development,  emanating  from  the 
nervous  centres;  or,  as  some  believe  the  blood-vessels  to  precede  the 
nerves,  by  their  impairment  affecting  the  peripheral  appendages  of 
the  primary  nucleus,  and  determining  the  normal  or  abnormal 
development  of  the  foetus. 

3d.  That,  if  some  of  the  nervous  centres,  essential  to  functional 
,  force  in  the  nutrient  vessels,  be  unfavorably  impressed,  or  partially 
interrupted  in  their  functions,  the  inevitable  result  would  be  abnor- 
mal development. 

3d.  That  the  encircling  of  the  limbs  of  the  foetus  by  adventitious 
bands  has  resulted  in  their  amputation. 

4th.  That  unfavorable  positions  of  the  foetus  in  utero,  influenced 
by  the  spherical  boundary  of  the  latter,  is  a  primary  cause  of  dis- 
tortion, more  especially  of  the  extremities. 

K.  W.  Tamplin,  F.  E.  C.  S.  E.,  Surgeon  to  the  Eoyal  Orthopoedic 
Hospital,  London,  in  his  fifth  lecture  of  a  course  delivered  in  that 
institution,  and  republished  at  Philadelphia,  thus  speaks  of  the 
cause  of  congenital  deformities  of  the  feet : 

"  These  consist  of  talipes  varus,  talipes  valgus  and  talipes  calca- 
neus. I  have  never  met  with  talipes  equinus.  You  will  recollect,  I 
stated  that,  in  my  opinion,  it  was  position,  and  position  alone, 
which  caused  these  malpositions  (or  rather  the  permanent  extreme 
natural  position,  for  this  is  its  real  character)  during  uterine  exist- 
ence ;  and  if  you  observe  the  character  of  these  three  deformities,  I 
think  you  will  have  little  difficulty  in  reconciling  the  possibility,  if 
not  the  probability,  of  this  being  the  case.  Take  the  first  men- 
tioned, talipes  varus;  there  are  many  positions  in  which  the  extrem- 
ities of  the  child  may  be  kept  while  in  utero,  which  would  better 
adapt  it  to  the  surrounding  interior,  jorowif^e^  the  feet  loere  inverted; 
and,  it  so  happens,  that  the  greater  number  by  far  of  congenital 
cases  consist  of  double  varus.  And  where  it  does  not  consist  of 
double  varus,  nothing  is  more  easy  to  account  for  than  one  or  the 
other  extremity  being  so  placed  that  the  foot  should  grow  in  that 


Defective  Physical  Formation.  13 

poLSition,  while  its  fellow  maybe  free  and  unconfined.  Then,  if  you 
refer  to  congenital  varns,  this  also  may  be  easily  imagined  —  that 
the  extremities  or  extremity  may  be  so  situated,  that  the  flat  surface 
of  the  feet  press,  more  or  less,  on  the  walls  of  the  uterus  —  if  not 
constantly,  sufficiently  to  influence  them  during  the  growth  of  the 
bones  and  ligaments ;  and,  be  it  remembered,  that  it  is  only  the  liga- 
ments and  muscles  that  we  find  affected,  the  bones  retaining,  in 
either  of  the  three  forms,  their  natural  proportions  and  relative  size, 
and  it  must  be  evident  that  it  would  not  require  any  force,  but 
merely  a  constant  position,  to  produce  this  effect,  at  least  it  is  so  to 
my  mind." 

It  is  an  undisputed  fact,  that  the  unfavorable  position  of  the  feet 
of  children  and  adults  has,  by  long  continuance,  resulted  in  per- 
sistent deformity,  and  that  so  diverse  in  character  as  to  produce  the 
several  varieties  alluded  to  by  Surgeon  Tamplin. 

Thorough  investigation  of  intra-uterine  life  has  well  determined 
that  the  foetus  is  liable  to  many  affections,  which  may  cause  various 
changes,  not  only  in  health,  but  in  physical  formation ;  the  facts 
furnishing  a  basis  for  the  deduction  of  inferences  as  to  malforma- 
tions. The  great  father  of  medicine,  Hippocrates,  asserted  that 
children,  while  contained  within  the  organ  of  gestation,  were  sub- 
ject to  unfavorable  impressions  from  falls,  blow^s  or  pressure  exerted 
on  the  abdominal  walls  of  the  mother;  Pare  expressed  similar 
views  in  regard  to  congenital  deformity;  J.  L.  Petit  believed  in  the 
alteration  of  the  germ,  or  an  aberration  of  the  formative  power. 
Dupuytren,  in  an  arrest  of  the  development  of  the  deficient  or 
deformed  parts  of  the  foetus ;  Breschel  and  M.  Sause  ascribed  as  a 
cause  the  existence  of  certain  articular  maladies;  Chaussier,  Del- 
pech  and  Guerin,  a  primitive  alteration  in  the  nervous  centres,  and, 
from  extended  observations,  attributed  certain  congenital  deformi- 
ties, as  that  of  talipes  and  other  contortions,  to  convulsions  occur- 
ring in  the  foetus. 

The  opinions  of  M.  Serres,  Geoffrey  Saint  Hilaire  and  Koux 
are,  that  the  evolution  of  the  organs  in  the  foetal  state  pro- 
ceeds in  strict  ratio  with  their  supply  of  blood;  consequently,  that 
atrophy,  imperfection,  or  absence  of  the  organs  generally,  is  attribu- 
table to  the  imperfection  or  absence  of  their  nutrient  arteries ; 
while   Tiedman    asserts*    that    the    nervous    system   is   developed 


*"  London  Medical  and  Physical  Journal,"  July,  1828. 


14  Ortbop^bia. 

before  any  other  part  of  tlie  body,  that  congenital  malformations 
or  anomalies  depend  upon  the  imperfections,  or  the  want  of  certain 
portions  of  the  nervous  system,  and  that  they  control  the  develop- 
ment of  the  embryo  to  the  determining  of  the  form  and  disposition 
of  the  organs ;  hence,  deformities  have  their  first  cause  in  the  irreg- 
ular development  of  this  system. 

The  absence  or  impairment  of  nervous  centres  having  been  con- 
sidered by  Guerin  as  a  cause  of  fcetal  deformity,  this  gentleman 
presented  supposed  evidence  to  sustain  this  opinion  ;  and  read  a 
paper  before  the  Academy  of  Science,  Paris,  presenting  specimens 
of  monstrosities  having  the  attendant  contortion  of  the  limbs.  He 
asserted  that  there  was  always  to  be  observed  a  perfect  relation 
between  the  absence  of  the  nervous  centres  (or  a  portion  of  them, 
the  result  of  which  is  muscular  contraction)  and  that  of  dislocating 
the  joints  in  the  foetus.  This  noted  Orthopaedist  premises  his  argu- 
ment in  favor  of  this  theory  by  the  following  remarks  : 

J'  The  observation  of  certain  monstrosities  presents  to  us,  in  a 
striking  manner,  the  combination  of  these  four  orders  of  facts, 
namely :  that  in  them  may  be  observed  at  the  same  time,  a  material 
lesion  of  the  nervous  centres,  the  retraction  of  the  totality,  or  of 
the  greater  portion  of  the  muscular  system  and  of  concomitant 
luxations,  a  vigorous  relation  between  the  seat,  the  extent,  and  the 
degree  of  the  nervous  lesion,  and  the  seat,  extent,  and  degree  of 
retraction ;  and,  finally,  a  relation  of  direction,  of  extent,  and  of 
degree  between  the  retraction  and  the  dislocation  which  it  produces." 
For  illustration,  he  presented  an  anencephalus,  in  which  there  was 
not  only  contraction  of  all  of  the  muscles,  producing  curvature  of 
the  spine,  but  actual  dislocations  of  the  joints.  He  furtlier  asserted 
that,  under  certain  circumstances,  an  arrest  of  development  is  the 
result  of  this  deficiency  in  the  nervous  centres. 

As  the  perfection  of  the  nervous  centres  is  essential  to  the  perfect 
formation  of  the  fostus,  we  must  infer  that  some  pathological  change 
had  taken  place  at  an  early  period  of  gestation  to  the  imjjairment 
and  destruction  of  the  nervous  centres ;  hence,  an  arrest  of  devel- 
opment and  contortion  are  the  results  of  abnormal  nervous  energy. 

As  an  aid  to  the  adequate  consideration  of  this  subject,  of  so 
much  interest  to  all,  we  have  introduced  several  engravings  repre- 
senting deformed  children ;  two  of  them  laboring  under  various 
congenital  malformations,  and  now  living  subjects,  and  one  simi- 


Defective  Physical  FouMATioy. 


15 


larly  afflicted  that  died  of  scarlet  fever  at  the  age  of  four  years  — 
the  drawings  having  been  made  from  photographs  of  the  patients. 

The  first  of  these  cases  (fig.  1)  is  a  striking  iUustration  of  arrest 
and  deficiency  of  development,  together  with  retraction  of  the 
muscles.     The  history  of  the  case  is  as  follows: 

Maggie  K ,  aged  tAventy  months,  was  brought  by  her  mother 

from  her  residence  in  the  country  for  treatment,  or  rather  to  obtain 

Fig.  1. 


GUI  cipinion  as  to  the  possibility  of  enabling  the  child  to  walk.  We 
could,  however,  only  give  a  favorable  opinion  as  to  the  ultimate 
accomplishment  of  the  desired  object. 

After  a  very  careful  examination,  we  advised  an  efi'ort  to  be 
made  to  relieve  the  child  from  its  utterly  dependent  condition  —  a 
sitting  posture  maintained  with  difficulty;  the  upper  limbs  being  so 
markedly  deficient  as  to  not  only  be  unavailable  in  any  effort  at 
locomotion,  but  of  no  assistance  to  the  child  in  keeping  an  upright 
position.  We,  at  the  same  time,  informed  the  mother  that  the 
severe  surgical  treatment  required  for  the  extension  of  the  lower 


16  OrTHOPjEDIA. 

limbs  would  possibly  endanger  the  child's  life,  but  that  its  deplora- 
ble and  nearly  hopeless  condition  would  fully  justify  the  effort  for 
improvement. 

Upon  inquiry  as  to  the  hereditary  disposition  in  the  families  of 
both  parents,  the  mother  made  this  statement :  "My  age  is  thirty- 
five  years ;  my  husband  is  about  forty-five.  We  enjoy  excellent 
health,  and  have  always  resided  upon  a  farm.  I  am  not  aware  of 
any  member  of  my  own  or  my  husband's  family  being  deformed. 
Our  families  can  be  traced  back  for  two  generations.  About  two 
weeks  after  becoming  pregnant  with  this  child,  to  the  best  of  my 
judgment,  I  was  thrown  out  of  a  sleigh  into  the  snow,  but  did  not 
sustain  any  injury  to  body  or  limbs,  and  consequently  gave  the  cir- 
cumstance but  little  consideration.  Nothing  else  unusual  occurred 
during  niy  pregnancy.  Previous  to  this  great  affliction  I  have  had 
several  children,  all  of  whom  enjoy  excellent  health,  and  are  of 
natural  form." 

The  malformation  of  the  child  cannot  be  readily  comprehended 
without  a  careful  examination  of  the  engraving.  The  legs  were 
flexed  upon  the  thighs,  and  the  thighs  upon  the  abdomen,  presenting 
the  appearance  of  an  extraordinary  development  of  the  thighs  and 
nates,  the  retracted  condition  giving  a  spherical  form  to  this  portion 
of  the  child's  body.  The  length  of  the  apparent  legs  from  the 
flexed  thighs  was  three  inclies,  the  feet  being  of  ordinary  size,  yet  hav- 
ing but  three  toes  on  each.  A  line  subtended  from  the  centre  of  the 
tuber  ischii  to  the  posterior  extremity  of  the  os  calcis  measured  four 
inches.  A  firm  tissue  beneath  the  skin  retained  the  legs  in  an 
arched  condition,  and  no  appearance  of  a  knee-joint  existed.  The 
limbs  superficially  presented  a  uniform  semicircular  curve  from 
the  abdomen  to  the  feet,  the  latter  being  slightly  adducted,  the  ankles 
having  free  motion. 

On  placing  the  child  upon  her  back,  the  thighs  seemed  movable 
upon  the  pelvis,  and  the  limbs  could  be  separated  laterally  to  a  nor- 
mal extent.  By  manipulation  a  very  limited  motion  was  also 
detected  in  what  appeared  to  be  the  middle  of  the  thigh,  giving 
indications  of  the  existence  of  a  knee-joint. 

The  discovery  of  these  yielding  points  induced  us  to  sever  sub- 
cutaneously  what  appeared  to  be  the  extended  posterior  muscles  of 
the  thigh,  on  both  legs,  two  inches  from  their  insertion  into  the  os 
calcis,  and  then  to  apply  extension,  with  moderate  force,  to  the  limbs. 
They  slowly  yielded,  and  developed  imperfect  knee-joints,  at  about 


Defective  Physical  Formation. 


17 


what  would  be  the  lower  third  of  normal  thighs.  The  left  limb 
extended  more  readily  than  the  right,  both  limbs  deficient  of  fibula, 
and,  for  want  of  the  maleola,  everted  feet. 

After  three  months'  effort  at  extension,  resulting  in  a  very  con- 
siderable yielding  of  the  limbs,  it  was  deemed  advisable  to  sever  the 
parts  as  before,  but  about  an  inch  higher  up,  and  to  not  more  than 

half  the  depth  of  the  first 
operation.  This  afforded 
most  decided  relief;  and 
in  about  a  month  from 
that  time  the  little  patient 
commenced  to  Avalk  with 
tolerable  firmness,  the 
right  leg,  however,  being 
shorter  than  the  left. 

Within  a  year  from  the 
last  operation,  we  severed 
a  portion  of  the  constrict- 
ed parts  in  the  right  leg, 
about  an  inch  above  the 
insertion  of  the  tendon 
upon  the  os  calcis.  This 
Avas  attended  with  rather 
an  alarming  result ;  sup- 
puration supervened,  and 
it  was  with  some  difficulty 
that  the  child  Avas  relieved 
—  the  leg  being  only 
slightly  improved  as  to 
length. 

However,  the  child  now 
walks  with  considerable 
freedom,  and  her  present 
condition  is  fairly  shown 
in  the  accompanying  en- 
graving (Fig.  2).  It  will 
be  observed  that  there  is 
a  deficiency  in  tlie  left 
forearm,  there  being  only  a  stump  of  about  two  inches  in  length 
from  the  elbow-joint,  and  that  covered  by  loose  integument.     From 


X8  Orthof^dia. 

this'  stump  a  prommence  proceeds,  very  similar  to  the  project- 
ing tip  of  an  elephant's  proboscis,  and  which  can  be  extended  at 
■will  —  in  fact,  made  so  useful  as  to  draw  a  pin  from  the  clothing,  or 
to  convey  food  to  the  mouth.  This  arm  is  movable  at  the  shoulder 
and  also  at  the  elbow-joint.  Within  the  loose  integument,  there  is 
a  rudiment  of  the  ulna,  if  not  of  the  radius,  of  about  two  inches  in 
length,  upon  which,  by  careful  examination,  there  can  be  distinctly 
felt  the  first  and  second  phalangeal  bones  of  two  fingers,  and  appa- 
rently a  rudimentary  portion  of  a  third.  These  parts  of  fingers 
have  the  power  of  flexion  and  extension  against  the  firm  segment 
of  an  ulna,  thus  grasping  and  retaining  small  objects.  The  right 
arm  remains  extended  from  the  shoulder,  where  there  is  normal 
mobility,  the  elbow  being  fixed  and  without  any  appearance  of  a 
joint.  To  this  arm  is  attached  an  imperfectly  developed  hand, 
having  carpal  and  metacarpal  bones,  terminated  by  three  webbed 
phalanges,  that  can  be  but  very  slightly  flexed  at  their  extremities, 
being  united  by  a  dense  integument  extending  to  the  distal  joints, 
where  there  is  only  a  partial  separation.  This  segment  of  a  hand  is 
quite  limited  in  motion,  and  it  is  only  by  approximating  it  to  the 
stump  of  the  left  arm,  that  it  can  be  used  to  convey  food  to  the 
mouth,  and  only  then  by  bending  the  neck  and  lowering  the  head 
obliquely  forward. 

Isot  having  any  desire  to  theorize  upon  the  primordial  develop- 
ment of  the  foetus,  we  have  simply  noted  the  condition  of  chil- 
dren whom  we  have  treated,  and  will  merely  recapitulate  the  several 
points  having  a  bearing  on  the  subject. 

First :  The  parents  were  of  normal  development,  in  the  enjoy- 
ment of  good  health,  and  void  of  hereditary  predisposition  to 
deformity. 

Second:  There  is  a  presumable  cause  for  the  deformity  of  the 
child  in  the  concussion  received  by  the  mother  two  weeks  after  con- 
ception. 

Third:  The  result  is  a  child  of  bright  intellect,  having  a  normally 
developed  head,  neck  and  body.  Hence,  there  was  no  apparent  defi- 
ciency in  the  cerebro-spinal  development,  and  a  uniformity  of  defi- 
ciency in  having  but  three  fingers  upon  the  right  hand  and  the  rudi- 
ments of  three  fingers  upon  the  left,  terminating  two  inches  below 
the  elbow,  and  an  arrest  of  development  in  the  feet,  three  toes  on  each. 

Fourth :  Eetraction  of  the  legs  upon  the  body ;  presenting  what 
would  appear  to  have  been  a  very  early  retraction  of  the  flexor 


Defective  Physical  Formation. 


19 


Fig.  3. 


muscles  of  the  thighs,  inserted  far  below  the  knee,  and  thns  closely 
approximating  the  heels  to  the  nates  —  the  largely  developed  mus- 
cles covering  the  bones  of  the  lower  limbs  so  as  to  obscure  the  knee 
joints. 

It  is  not  improbable  to  suppose  the  right  arm  to  have  been  held 
extended  by  a  rigidity  of  the  muscles  at  a  very  early  period  of  ges- 
tation ;  and  the  elbow  joint  rendered  thus  fixed  so  firmly  in  the 
erect  position  by  the  condensing  of  the  surrounding  tissue  —  all 
tending  to  prove  the  unfavorable  influence  to  have  been  of  early 
date  in  the  progress  of  development. 

The  accompanying  illustration  represents  a  case  of  arrest  of 
development  of  great  uniformity;  the  deficiency  being  confined  to 
the  feet  and  hands.  The  feet  were  flexed  firmly  upon  the  legs,  the 
distal  extremity  of  the  os  calcis  pointing  downward,  and  upon 
which  the  child  could  not  have  maintained  an  erect  position,  with- 
out assistance. 

From  this  dependent  condition  the  child  was  speedily  relieved, 
having  been  brought  for  treatment  to  the  "  Institution  for  the  Eelief 

of  the  Euptured  and  Crip- 
pled," when  about  four  weeks 
old.  The  photograph  was  tak- 
en when  the  child  was  one 
year  old. 

The  deformity  in  this  case 
consists  in  a  deficiency  of  the 
index  and  middle  digits  and 
the  carpal  and  metacarpal 
bones  of  both  hands;  and  of 
the  middle  and  adjoining  toes 
and  corresponding  tarsal  and 
metatarsal  bones  of  both  feet. 
In  this  instance  no  hereditary 
predisposition  can  be  traced  to 
the  parents,  nor  apparent  le- 
sion of  the  cerebro-spinal  sys- 
tem of  the  child ;  nor  is  there 
record  of  any  injury  sustained 
by  the  mother  during  gestation.  In  both  of  these  cases  there  has 
been  arrest  of  development  and  muscular  retraction.  In  the  first 
one,  of  the  flexors  of  both    the  lower  limbs,  to  an   extraordinary 


20 


Orthop^dia. 


degree.  In  the  second,  of  the  flexors  of  the  feet,  producing 
talipes  calcaneus.  Each  of  the  children  possessed  good  health, 
and  a  normal  condition  of  the  mental  faculties. 

The  third  case  we  present  is  one  that  cannot  be  attributed  to 
spasmodic  contraction  of  the  muscles  during  intra-uterine  develop- 
ment, as  it  is  not  a  distortion  of  the  joints,  but  an  actual  angular 
bending  of  the  lower  third  of  the  tibia  and  fibula,  without  any 
retraction  of  the  muscles,  other  than  that  of  a  slight  flexion  of  the 

Fig.  4. 


toes.     This  was  relieved  by  opposing  graduated  pressure  and  coun- 
ter-pressure applied  to  the  limb,  without  restriction  in  exercise. 

This  child  was  first  presented  for  treatment  at  the  "  Institution  for 
the  Eelief  of  the  Ruptured  and  Crippled,"  at  the  age  of  two  years. 
(Figure  4.)  The  mother  appeared  delicate,  but  said  that  she 
enjoyed  good  health,  as  did  also  the  father,  who  is  a  robust  laboring 
man.  The  mother  had  no  recollection  of  having  received  an  injury 
during  pregnancy  with  this  child,  and  the  deformity  was  discovered 


Defective  Physical  Formation. 


21 


by  the  midwife  on  its  delivery.  Tlie  patient  was  under  treatment 
for  two  years,  when  the  limb  was  restored  to  normal  form.  (See 
fig.  5.) 

F/y.  5. 


Another  case  of  angnlar  curvatnre  of  the  tibia  and  fibula  came 
under  our  notice  for  treatment  where  both  legs  were  bent  inward 
and  nearly  at  a  right  angle.  The  tibia  and  fibula  were  bent  at  the 
lower  third  of  the  leg,  the  feet  being  perfect  in  form.  The  mother, 
a  colored  woman,  strong  and  healthy,  stated  that  when  about  three 
months  advanced  in  pregnancy  she  was  compelled  to  jump  from  a 
second-story  window  to  the  pavement  below,  but  apparently  sus- 
tained no  other  injury  than  that  of  a  severe  shock,  which  did  not, 
however,  prevent  her,  even  for  a  day,  from  performing  her  ordinary 


22 


Orthopjedia. 


labor,  that  of  laundress.  Treatment  was  commenced  with  this 
child  when  six  months  old,  a  similar  course  to  that  of  the  former 
case  being  pursued  and  continued  for  two  years,  ending  in  a  com- 
plete restoration  to  normal  form. 

Case  No.  6  is  of  a  female  child,  primipara,  delivered  by  a  mid- 
wife, who  stated  that  after  the  birth  of  the  child  she  observed  a 
^sand  encircling  its  right  leg  below  the  knee,  which  she  divided  with 
the  scissors,   the   band   leaving   a  mg.%. 

deep  cincture,  as  represented  in 
the  engraving  (fig.  6).  The 
mother,  a  strong,  healthy  young 
woman  about  eighteen  years  of 
age,  brought  the  child,  when  six 
months  old,  for  treatment  of  varus 
of  the  impaired  leg.  Upon  the 
dorsum  of  this  foot  the  superficial 
integument  was  greatly  hyper- 
trophied,  a  condition  that  inter- 
fered very  much  witli  the  restora- 
tion of  the  foot  to  its  proper  posi- 
tion. The  drawing  was  made 
when  the  child  was  two  years  old, 
the  foot  being  represented  as  in 
its  original  condition,  in  order  to 
give  a  better  comprehension  of  the 
case.  At  this  age  the  cincture  re- 
mained as  at  first  observed,  though  ^^^  1^^ 
the  limb  was  equal  to  its  fellow  '==^ 
in  size  and  strength.  It  was  quite  ^^.^^^ 
apparent,  however,  that  a  slight  -^-=^ 
increase  of  the  stricture  made  during  foetal  existence  would  liave 
arrested  the  circulation  of  the  blood,  and  resulted  in  amputation  of 
the  limb. 

This  case  tends  to  induce  the  belief  that  amputations  in  utero  are 
made  possible  by  encircling  adventitious  bands  during  gestation. 

The  only  opposite  view  urged  against  the  fact  of  such  amputa- 
tions taking  place,  is,  that  in  cases  of  deficiency  of  a  limb,  the 
amputated  portion  has  not  been  found  on  delivery  of  the  child. 
But  may  not  this  be  from  the  lack  of  careful  examination  of  the 
placenta  ? 


Defective  Physical  Formation. 


23 


The  amputation  taking  place  at  a  very  early  period  of  gestation, 
when  the  member  is  very  small,  the  missing  portion  may  have 
become  disintegrated.  In  this  case,  the  most  probable  inference  is 
that  the  adventitious  band  was  formed  when  the  child  was  quite 
advanced  in  gestation,  as  there  was  no  apparent  impairment  of  the 
blood-vessels,  which  had  attained  sufficient  size  and  strength  to 
maintain  the  requisite  nourishment  of  the  limb.  ♦ 

From  the  cases  here  presented  it  is  reasonable  to  entertain  the 
opinion,  that  an  arrest  of  development  is  the  cause  of  deficiency  in 
a  limb  — as  that  of  a  fore-arm,  and  attached  thereto  a  rudimentary 
terminal  portion,  or  a  deficiency  in  the  number  of  digits,  carpal  and 
tarsal  bones,  as  shown  in  the  third  engraving.  Also,  that  the  defi- 
ciency of  a  limb,  having  a  regularly  rounded  terminus,  may  be  the 
result  of  an  amputation,  from  an  encircling  of  the  limb  by  an 
adventitious  band,  either  at  an  early  stage  of  development,  or  only 
a  partial  impression  made  at  an  advanced  period,  as  in  the  case 
represented  by  the  fifth  engraving. 

The  seventh  engraving  represents  a  child  having  both  limbs 
impressed  with  these  cinctures,  including  one  foot  —  the  child  now 
living,  July  10,  1872 : 

Edward  Molony  (Fig.  7),  aged  four  months,  of  Irish  parentage, 
brought  to  the  Dispensary  department  of  the  "Hospital  for  the 

Belief  of  the  Ruptured  and  Crippled," 
requesting  only  the  relief  of  the  [club- 
foot of  the  child,  when,  on  examina- 
tion, these  cinctures  in  the  limbs  were 
observed. 

The  parents  of  this  child  were  both 
healthy.  The  mother,  twenty-five 
years  of  age,  had  never  complained 
of  any  uterine  trouble  —  had  three 
children  at  full  term  of  gestation  — 
two  having  perfect  limbs.  Forceps 
were  used  in  the  first  labor;  the  two 
following  labors  were  natural  and 
easy.  Subject  of  present  history 
quickened  at  fourth  month  of  uterine 
life,  and  was  felt  most  in  the  right  side. 
During  the  gestation,  a  girl,  with 
marked  talipes-equino  varus,  resided  in 


m^.n. 


24  OrTHOPjEBIA. 

same  room  with  the  mother,  exciting  her  constant  fear  of  a  like  de- 
formity afflicting  her  expected  babe.  A  street  musician  with  drop- 
hand,  frequently  came  by  her  door  during  this  period  of  gestation. 
At  the  birth  of  this  child  no  cords,  either  natural  or  adventitious, 
were  discovered  encircling  the  limbs ;  cinctures  were  found,  as  rep- 
resented in  the  engraving,  near  the  middle  of  the  right  leg  extend- 
ing to  the  bone.  Above  and  below,  the  leg  was  of  normal  size,  but 
flabby ;  the  foot  of  this  limb  presents  a  case  of  taliiaes  varus,  having 
tense  contraction  of  the  plantar  fascia. 

On  the  left  leg,  the  cincture  is  immediately  above  the  maleoli, 
quite  to  the  bone ;  another  encircling  the  foot  over  the  metatarso- 
phalangeal articulation,  shallow  compared  with  the  others.  These 
two  cinctures  present  the  appearance  of  a  cord  having  been  passed 
round  the  leg,  and  crossed  on  the  instep  and  round  the  foot.  The 
stricture  here  has  seriously  affected  the  foot,  which  is  greatly  hyper- 
trophied,  and  apparently  contains  misplaced  metatarsal  bones  —  all 
this  portion  of  the  foot  presenting  a  ball-like  appearance,  having 
rudimentary  toes  projecting. 

In  reference  to  blemishes,  their  cause  cannot  be  satisfactorily 
explained.  They  are  presented  in  some  children  in  most  extra- 
ordinary forms  and  degree,  such  as  simple  discoloration,  growth  of 
hair  on  extraordinary  parts,  and  of  different  color  iipon  the  same 
person  or  parts  of  the  body.  By  persons  of  vivid  imagination,  the 
idea  is  often  entertained  that  these  blemishes  on  children  are  simi- 
lar to  or  resemble  some  object  that  has  seriously  impressed  the 
mother's  mind  during  the  period  of  gestation. 

In  the  breeding  of  horses,  it  is  a  very  common  practice  to  place 
various  markings  of  white  paint  upon  the  stallion,  in  order  that  the 
foal  may  exhibit  a  similar  appearance,  and  it  is  said  that  the  desired 
object  has  been  obtained  in  this  way.  This  device  is  of  very  ancient 
date,  as  we  have  before  remarked. 

Regarding  the  influence  of  these  mental  impressions,  many 
mothers  have  been  impressed  with  the  idea  that  the  remembrance  or 
ideal  of  some  unfavorable  circumstance,  occurring  long  before  the 
birth  of  their  children,  would  be  indelibly  stamped  upon  them,  is  a 
matter  of  popular  and  almost  universal  belief.  That  there  was  a 
true  representation  of  the  object  thus  impressing  the  enciente  is  not 
so  apparent  to  others  as  to  the  mother ;  yet  an  abnormal  appear- 
ance, and  on  the  part  designated  by  the  mother  previous  to  the  birth 
of  the  child,  has  been  in  numerous  instances  verified. 


Defective  Physical  Formation.  25 


CONGENITAL   LUXATION. 

To  Guerin,  of  Paris,  and  Prof.  John  M.  Carnochan,  of  New  York, 
we  are  indebted  for  some  very  valuable  information  upon  the  sub- 
ject of  congenital  luxation  of  the  hip,  particularly  as  the  numbei 
of  subjects  thus  afflicted  has  been  so  limited  as  to  aiford  but  little 
practical  knowledge  in  the  way  of  treatment;  and  their  writings 
have  done  much  toward  attracting  general  attention  to  this  phase 
of  aberration,  which  certainly  has  an  equal  claim  to  the  skill  of  the 
surgeon  with  the  more  commonly  observed  abnormal  conditions  of 
suffering  humanity. 

The  joint  most  commonly  affected  is  the  hip,  and  cases  are  often 
presented  in  which  both  the  hips  are  luxated,  though  the  other 
Joints  are  equally  liable  to  congenital  dislocation,  arising  from  the 
same  and  generally  admitted  cause  of  these  abnormalities,  namely, 
muscular  retraction. 

When  the  tendency  to  congenital  luxation  arises  at  an  early  period 
of  gestation,  the  articulating  cavities,  it  is  reasonable  to  suppose, 
are  of  imperfect  formation;  and  the  luxation  may  be  either  partial 
or  complete.  Hence,  in  some  cases,  the  child's  true  condition 
remains  undiscovered  for  two  or  three  years  after  birth,  when  it  is 
made  known  by  its  feeble  attempts  at  locomotion.  After  this  period, 
complete  dislocation  ensues,  and  the  final  condition  of  the  person  is 
as  represented  in  the  accompanying  engraving  (fig.  8),  the  copy  of  a 
photograph  of  a  patient  who,  when  about  four  years  old,  was  placed 
under  our  treatment,  and  is  now  seventeen  years  of  age. 

The  luxation  in  this  case  was  first  discovered  by  the  mother,  when 
the  child  was  nine  months  old.  She  immediately  conferred  with 
her  physician,  who  informed  her  that  it  would  be  impossible  for  the 
child  ever  to  walk.  Subsequently,  the  child  was  placed  in  a  chair, 
which,  by  the  propelling  power  of  its  legs  and  feet,  it  moved  about 
the  floor  —  remaining  in  this  condition  until  six  years  of  age. 
During  this  period  the  mother  died,  and  the  charge  of  the  child 
reverted  to  an  aunt  who,  shortly  after,  desired  our  opinion  as  to  the 
feasibility  of  placing  the  little  cripple  on  crutches. 

Upon  examination,  we  found  the  thighs  flexed  upon  the  body, 
with  a  disposition  to  yield  at  the  hips;  and  the  knees  unim- 
paired. 

After  two  years'  treatment,  the  patient  was  enabled  to  walk,  inde- 
pendently of  support  to  body  or  limbs ;  and  at  fifteen  years  of  age 


26 


Orthop^bia, 


danced  with  as  much  ease  as  others  of  the  same  age.     This  facility 
in  dancing  has  been  noticed  in  others  similarly  affected. 

The  effect  of  the  dislocation  of  the  heads  of  both  femora,  is  to 
produce  a  yery  jDeculiar  appearance  in  the  locomotion  of  the  indi- 
vidual. The  want  of  a  firm  mg.&. 
central  axis  permits  alternate 
elevation  and  depression  of 
the  hips,  bending  the  body 
alternately  in  a  lateral  direc- 
tion at  each  step.  The  mo- 
tion is  not  such  as  is  observed 
in  a  bow-legged  child,  or  in 
a  sailor,  who  has  some  firm- 
ness when  the  step  is  taken, 
but  the  gait  is  one  of  a  con- 
stantly yielding  movement, 
quite  peculiar,  and  determin- 
ing the  condition,  at  once, 
to  an  experienced  observer. 

This  malformation  has 
been  traced  through  many 
generations  of  individuals  of 
the  same  descent.  Dupuy- 
tren  relates  the  history  of  a 
family  of  very  aged  persons, 
in  which  a  woman  of  eighty; 
two  maternal  aunts, each  sev- 
enty years  of  age ;  and  a  sis- 
ter's child,  were  all  thus  af- 
flicted. In  this  family,  a 
woman  who  married  a  sound 
man  had  a  daughter  with 
this  ailment.  The  daughter ^^^^ 
married  a  sound  man,  whose 
father  had  connate  luxation 
of  both  femurs;  and  she  gave  birth  to  four  children,  in  two  of 
whom  was  represented  the  hereditary  infirmity. 

This  hereditary  disposition,  that  cannot  be  disputed,  invites  con- 
sideration as  to  the  cause  of  the  ailment;  it  is  said  to  be  muscular 
retraction.     Is  it  not  possible  that  there  may  be  an  arrest  of  devel- 


Defective  Physical  Formatiox.  27 

opment  of  the  cotyloid  cavity  ?  For,  in  nearly  all  of  the  cases  of 
this  kind,  the  subjects  have  been  in  possession  of  more  than  ordin- 
ary good  health,  and  devoid  of  any  appearance  of  spasmodic  dispo- 
sition, or  spastic  contraction  of  muscles,  the  supposed  cause, 
primarily,  of  intra-uterine  ailments  attributed  to  retraction  of 
muscles. 


ANCIENT   TREATMENT   OF   DEFORMITY. 

As  we  have  stated,  the  treatment  of  deformities  is  evidently  of 
very  ancient  date.  Hippocrates  taught  the  treatment  of  talipes  500 
years  before  the  Christian  era  ;  and,  from  his  time  to  the  sixteenth 
century,  there  is  no  other  recorded  dissertation  to  be  found  on  this 
subject.  It  is  not  to  be  inferred,  however,  that  in  the  interim  there 
were  no  efforts  made  for  the  relief  of  these  cases :  The  works  of 
this  great  physician  were  preserved;  and  his  instructions  (though 
no  doubt  greatly  modified)  made  available  by  his  successors.  That 
others  treated  deformities  of  the  feet  during  the  life-time  of  Hippo- 
crates is  certain ;  for,  in  his  writings  on  the  subject,  he  instructs 
that,  after  the  bandage  has  been  applied,  the  foot  should  be  kept  in 
a  proper  position  by  means  of  a  leaden  shoe  made  in  the  form  of 
those  of  Ohio ;  giving  at  the  same  time  the  model  of  boots  to  be 
applied  if  these  should  prove  ineffectual.* 

After  the  days  of  the  father  of  medicine,  Marcus  Aurelius  Severi- 
nus  gave  a  treatise  upon  talipes ;  and  following  him,  Ambrose 
Pare.  We  learn  from  the  works  of  the  latter,  as  translated  from 
the  Latin  in  1665,  the  construction  of  an  artificial  arm,  hand,  and 
leg,  by  which  extraordinary  skill  is  displayed ;  and  of  apparatus  for 
the  relief  of  every  variety  of  deformity  of  the  human  body —  some 
of  which  were  very  ingeniously  devised,  and  would  compare  very 
favorably  with  some  of  those  in  use  at  the  present  day. 

In  1630,  Fabricius  Hildanus  devised  a  method  of  treatment  of 
club-foot;  an  apparatus  for  extending  contracted  fingers,  and  an 
extension  splint  for  the  relief  of  contracted  knee  joints.*  This  last 
is  described  as  follows :  "  About  the  middle  of  the  splint  is  a  screw, 
to  which  is  attached  a  ring,  which  encircles  the  knee.  A  pad  is 
interposed  between  the  knee  and  the  patella ;  and  by  turning  the 
screw,  the  joint  is  drawn  backward  toward  its  natural  position." 

*  "  Observationam  et  Curationum  Medico  Chirurgicarum." 


28  Orthopjedia. 

This  description  is  a  tolerable  representation  of  Amesbury's  splint 
for  a  similar  purpose,  which  is  now  in  general  use. 

In  1651,  Glisson  treated  deformity  by  extension.  He  states: 
"  That  the  parts  may  the  more  be  stretched,  hang  leaden  shoes  on 
the  feet,  and  fasten  Aveights  to  the  body  that  parts  may  the  more 
easily  be  extended  to  an  equal  length."  This  seems  to  be  the  earli- 
est writer  who  recommends  extension  by  weights  and  cords  —  now 
practiced  as  novel  treatment,  and  in  great  repute  ;  not  only  for  the 
relief  of  deformity  arising  from  contraction  of  muscles,  but  in  the 
treatment  of  hip-disease,  and  fracture  of  the  bones  of  the  lower 
extremities;  yet  217  years  have  elapsed  since  the  introduction  of 
this  therapeutic  agent. 

For  the  treatment  of  deformed  limbs  and  of  the  back,  Scultetus, 
in  1656,  described  a  mode  of  treatment  by  extension  and  counter- 
extension  from  the  head  and  feet.  Two  years  later,  Circoeus 
described  shoes  for  the  cure  of  talipes,  very  like  in  appearance  and 
quite  equal  in  principle  to  some  of  the  apparatus  in  favor  at  the 
present  day. 

It  would  appear  that  in  that  day,  as  now,  there  were  certain 
periods  in  which  the  medical  profession  became  more  than  ordin- 
arily interested  in  special  subjects.  Some  twenty-nine  years  elapsed, 
when  Isaac  Mincius  divided  the  sterno-cleido-mastoid  muscle  for 
the  cure  of  torticollis,  and  Heister  invented  steel  supports  for  the 
treatment  of  spinal  curvature.* 

Up  to  this  period  the  treatment  of  deformity  of  the  human  body 
was  altogether  adventurous,  when  M.  Andry's  works  appeared,! 
and  the  term  Orthopcedia  was  for  the  first  time  given  as  a  proper 
designation  for  the  treatment  of  deformity  in  children.  Since  then 
it  has  been  applied  to  the  treatment  of  deformity  in  general.  This 
author  states  that  he  has  "  devised  the  term  Orthopsedia  from  two 
Greek  words:  Orthos,  straight,  and  pais,  a  child."  And,  that 
"orthopsedia"  is  to  express  in  a  single  term,  the  plan  of  his  work; 
which  is  to  teach  different  modes  of  preventing  and  correcting  the 
bodily  deformities  of  children. 

An  interim  of  about  fifty-five  years  now  occurs,  until  the  time  of 
Venel,  of  the  Canton  of  Berne,  and  Tiphaisne,  of  Paris;  the  latter 
a  mechanic,  and  the  former  a  professional  adventurer,  who,  from 

*  Article  in  the  "  British  Medical  and  Chirurgical  Keview,"  for  October,  1861. 
f  "L'  Orthopaedic,"  par  M.  Andry,  1741. 


Defective  Physical  Formation.  29 

selfish  motives,  kept  his  discoveries  in  treatment  as  secluded  as  pos- 
sible. To  accomplish  his  unprofessional  designs,  he  established  an 
institution  in  which  he  attained  much  notoriety  for  his  successful 
treatment  of  talipes.  His  enterprise  was  only  of  short  duration, 
and  terminated  at  his  death.  Dr.  Ehremann,  a  patient  of  Venel, 
acquired  a  tolerable  knowledge  of  his  apparatus  and  treatment, 
which  was  subsequently  practised  by  Briickner,  of  Gotha,  and 
Naumberg,  of  Erfurt.  The  latter  published  the  results  obtained 
from  Venel's  treatment  in  1796.* 

In  the  preface  of  a  translation  of  Scarpa's  monograph  "  Sulle 
Piedi  Ferti,"  into  German,  by  Malfatti,  a  description  is  given  of  the 
proceedings  of  Scarpa,  which  led  to  the  construction  of  his  cele- 
brated, and,  with  slight  modifications  by  noted  Orthopedists,  the 
most  approved  shoe  at  the  present  day  for  the  treatment  of  talipes 
varus  and  valgus.  It  is  stated  that,  in  1781,  Scarpa  resided  in  Paris, 
and  passing  by  Tiphaisne's  abode,  he  noticed  in  the  window  draw- 
ings of  deformed  feet  and  of  those  that  had  been  cured.  He  became 
immediately  very  desirous  of  obtaining  information  in  regard 
to  this  successful  treatment,  and  sought  an  acquaintance  with 
Tiphaisne.  The  only  information  he  derived  thereby  was  from  an 
incidental  remark  made  by  this  skilful  man  in  the  course  of  general 
conversation,  viz. :  "  Nature  will  not  yield  to  violence,  but  only  to 
gradual  force."  This  excited  still  more  the  curiosity  of  this 
ingenious  surgeon,  and  he  determined  to  obtain  the  information  at 
almost  any  peril  —  not  for  any  sinister  purpose,  but  that  he  might 
make  known  his  discoveries  for  the  benefit  of  his  suffering  fellow- 
man.  It  is  stated  that  Scarpa  availed  himself  of  an  opportunity, 
during  the  temporary  absence  of  Tiphaisne,  to  enter  the  private 
room  of  the  latter  through  favor  of  the  housekeeper,  where  he 
found  only  a  steel  spring  lying  on  a  cushion. 

Although  his  conduct  in  this  special  matter  is  not  commendable, 
yet  it  does  not  detract  from  his  indomitable  energy  and  ingenuity, 
by  which  he  gave  to  posterity  so  valuable  an  invention.  From  this 
very  circumstance  it  is  most  reasonable  to  award  the  credit  of  the 
invention  to  Scarpa,  the  most  eminent  anatomist  and  surgeon  of  his 
day.  He  published  his  remarkable  work  about  the  beginning  of  the 
nineteenth  century,  after  having  made  himself  familiar  with  the 
ailment,  and  the  condition  of  the  deformity,  which  latter  know- 

*  "  xA.bhandluno:  iiber  Verkriimmunsren." 


30  Orthop^dia. 

ledge  no  one  had  hitherto  acquired.  He  discovered  and  asserted 
that  the  bones  of  the  tarsus,  in  cases  of  talipes,  are  never  luxated, 
but  only  partially  separated  from  mutual  contact  and  turned 
according  to  their  smallest  axis.  In  all  probability  it  was  the 
knowledge  of  this  important  and  impressive  truth  —  that  gradually 
increased  elastic  force  is  the  most  effectual  meajis  of  redressing  dis- 
tortion, hoth  of  body  and  limbs,  when  resulting  from  contracted  mus- 
cles —  that  facilitated  the  designing  and  construction  of  his  cele- 
brated shoe,  so  simple  in  design,  and  yet  complete  and  efficient  in 
purpose,  because  of  the  continued  leverage  force  from  elastic 
springs,  tending  to  oppose  the  contorted  form  of  the  yielding 
foot. 

The  application  of  elastic  force  is  one  of  the  most  important 
practical  principles  in  the  construction  of  apparatus  to  overcome 
contraction  of  muscles  or  other  elastic  tissues.  Fixed  force  will,  if 
applied  to  contracted  muscles,  be  resisted,  to  the  exhaustion  of  the 
vital  energy  of  the  parts. 


AlfrCIElfT   TEEATMEXT    OF   SPIXAL   DEFOEMITIES. 

The  treatment  of  spinal  deformity  in  the  time  of  Hippocrates 
was  —  as  we  gather  from  his  writings,  in  which  he  gives  a  descrip- 
tion of  the  structure  of  the  spine  and  the  modes  of  treatment  when 
contorted  —  accompanied  with  some  very  rude  methods.  One  of 
these  was  to  suspend  the  patient  by  the  feet,  to  produce  what  he 
termed  succussion.  Another,  was  that  of  extending  the  patient,  by 
means  of  bands  under  the  arms  and  about  the  loins,  and  then 
forcing  the  spine  inwards  by  the  use  of  a  lever. 

This  most  dangerous  treatment  was  also  practiced  by  Pare  in  the 
sixteenth  century.*  Means  were  devised  by  tl^is  extraordinary  phy- 
sician for  the  treatment  of  all  manner  of  deformity  —  even  that  of 
cleft  palate,  by  the  application  of  a  well-fitting  gold  or  silver  plate 
to  the  defective  palatine  roof,  by  means  of  an  ingenious  method  of 
retaining  them  n?- s/?'w;  and,  to  the  present  day,  no  improvement 
has  been  made  upon  his  appliance.  Recently,  however,  it  has  been 
superseded  by  a  most  ingenious  device  made  of  India  rubber, 
enabling  the  individual  thus  afflicted  to  articulate  distinctly,  and  to 

*  "  Memoirs  de  I'Academie  Roval  de  Chirurgie  de  Paris," — "Vol.  IV. 


Defective  Physical  Formation.  ^\ 

swallow  fluids  with  normal  facility,  by  ISTorman  W.  Kingsley,  M.  D., 
a  noted  dentist  of  the  city  of  New  York. 

Fare's  metallic  corset  is  said  to  have  been  the  earliest  piece  of 
mechanism  intended  for  the  relief  of  the  distorted  spine ;  and,  as 
shown  by  the  drawings,  does  not  differ  very  materially  from  an 
apparatus  constructed  by  Dr.  Abbe,  of  Boston,  and,  subsequently, 
by  Dr.  Brewster,  of  New  York  city,  in  1850 ;  being  a  perforated 
metallic  casing  of  tolerable  form,  and  in  segments  hinged  together, 
into  which  the  body  tended  to  conform  by  continued  pressure. 

In  1768,  M.  Le  Vasher  devised  an  apparatus  for  suj)porting  the 
head  and  gradually  extending  the  spine  in  cases  of  curvature.  A 
Strong,  well-fitting  corset,  applied  to  the  body,  sustained  a  movable 
iron  rod  fixed  to  a  socket  behind,  and  extending  over  the  head  in 
the  form  of  an  arch.  From  this  arch  was  suspended  a  curved  bar 
of  polished  steel,  extending  from  ear  to  ear,  and  to  which  were 
attached  chin  and  occipital  straps.  When  adjusted,  the  head  was 
held  erect,  and  the  weight  of  the  same  taken  from  the  spine,  a  most 
desirable  apparatus  for  the  relief  of  caries  of  the  cervical  vertebrae. 

In  1779,  David,  of  Rouen,  Prance,  and  Pott,  of  England,  intro- 
duced, probably,  the  first  rational  ideas  of  the  pathology  of  spinal 
disease,  and  placed  the  treatment  on  a  scientific  basis.  Schmidt,  of 
Marburg,  in  1794,  constructed  a  similar  supporter,  the  base  to  be 
placed  upon  the  costa  ilii,  with  two  metal  bars  to  pass  up  on  either 
side,  terminating  at  the  axilla,  and  having  crutches  which  could  be 
elevated  to  the  extension  of  the  body,  and  retained  in  situ  by  a  band 
across  the  dorsum  of  the  patient.  This  form  of  support  is  now  in 
common  use  for  the  treatment  of  caries  of  the  sjDine,  both  in  this 
and  the  old  countries.  Mr.  Sheldrake,  a  very  ingenious  mechanic, 
of  London,  and  a  man  possessed  of  more  than  ordinary  practical 
good  sense,  in  or  about  the  same  year  published  a  book,  in  which  he 
described  a  variety  of  means  for  the  treatment  of  deformity,  and 
made  some  excellent  suggestions  as  to  the  construction  and  use  of 
apparatus,  except  in  the  case  of  caries  of  the  spine.  This  ailment 
he  treated  by  extension  and  confinement  in  the  recumbent  position, 
a  treatment  advised  by  Darwin  in  his  Zoonomia  (vol.  2),  who  gave 
the  first  intimation  of  the  supposed  advantage  of  keeping  patients, 
laboring  under  spinal  disease,  in  this  position  during  treatment. 
This  was  in  1796,  and  it  was  subsequently  highly  extolled  as  a 
treatment  of  disease  of  the  hips,  and,  as  an  auxiliary  extension  by 
means  of  attached  weights  and  pullies  to  the  foot  or  feet  of  the 


32  Orthopjedia. 

patient,  is  favorably  considered  at  the  present  day  by  many  eminent 
surgeons  abroad  and  at  home,  while  others  condemn  it  as  comprom- 
ising the  normal  energies  of  the  patient  to  the  increase  of  impair- 
ment of  health  and  aggravation  of  the  abnormal  condition.  And 
we  claim  the  verification  of  this  in  many  cases  thus  treated. 


S-UKGICAL   MEAN'S   OF   EEDEESSING   DEFOEMITT. 

Section  of  the  tendo- Aehillis  Avas  favorably  considered  as  a  method 
of  treatment  for  talipes  for  nearly  a  century  before  its  introduction 
as  a  generally  recognized  practice,  and  is  now  so  modified  as  to  make 
it  a  safe  and  eflBcacious  mode  of  treatment  in  the  hands  of  skilful 
surgeons.  It  will  be  seen,  by  reference  to  the  annals  of  medicine, 
that,  as  far  back  as  1769,*  Hains,  a  surgeon  of  Dijon,  with  the  view 
of  establishing  the  fact,  availed  himself  of  a  series  of  experiments, 
the  result  of  which  was  favorable.  He  severed,  both  partially  and 
wholly,  the  tendo- Aehillis  of  cats  and  dogs,  and,  although  the  ani- 
mals were  left  entirely  to  themselves,  and  no  precaution  taken  to 
exclude  the  air,  all  the  wounds  became  perfectly  healed.  Subse- 
quently, and  within  a  very  limited  period  thereafter,  Molinellif 
opposed  the  generally  received  opinion  of  that  time,  and  stated  that 
wounds  of  the  tendo-Achilles  do  not  heal  favorably ;  yet  he  made  a 
statement  in  the  "  History  of  the  Academy  of  Bologna,"  that  four 
cases  were  noticed  by  him,  in  which  the  tendo-Achillis  was  divided 
transversely,  and,  being  accidental,  was  complicated,  yet  healed 
kindly. 

In  relation  to  the  division  of  tendons  as  a  treatment  for  deformity 
of  the  human  feet,  the  earliest  information  we  have  upon  the  sub- 
ject is  that  Thelsenius,  of  Frankfort,  proposed  that  the  tendo- 
Achillis  should  be  severed  in  the  case  of  a  young  lady,  seventeen 
years  of  age,  laboring  under  talipes  varus,  and  that,  under  his  direc- 
tion, the  operation  was  performed  March  26,  1784,  by  a  surgeon 
named  Lorenzi.  This  is  reported  as  a  successful  operation,  although 
the  external  integument  was  largely  divided  before  dividing  the 
tendon,  when  the  heel  descended  two  inches.  The  cure  is  said  to 
have  been  complete  on  the  12th  of  May,  in  the  same  year,  fifty-two 

*  "  Journal  de  Medecin/'  Janv. 

+  "  Comment.  Academ.  Scientaire:  Bononiens,"  p.  189-196  :  1773. 


Defective  Physical  Formation.  33 

days  being  a  comparatively  limited  period  for  the  cure  of  club-foot, 
1.  e.,  to  heal  and  perfectly  straighten  the  foot  after  so  severe  an 
operation. 

In  the  year  1806,  on  the  10th  of  May,  the  operation  of  Lorenzi 
was  repeated  by  Saratorius  in  a  case  of  talipes  equinus,  resulting 
from  abscesses  on  the  posterior  of  the  leg,  the  patient  being  a  boy 
thirteen  years  of  age.  The  first  step  of  procedure  was  to  apply  a 
tourniquet  to  the  femoral  artery.  A  longitudinal  incision,  four 
inches  in  length,  was  then  made  over  the  tendo-Achillis,  the  integ- 
ument dissected,  and  the  fascia  divided  on  a  director  to  the  same  ex- 
tent. The  tendon  was  severed  transversely,  but,  the  foot  not  yield- 
ing, the  incision  was  extended  to  the  os  calcis ;  the  cicatrices  were 
severed  and  the  tendon  isolated,  but  the  Joint  failed  to  yield.  Sara- 
torius informs  us  that  he  employed  his  whole  strength,  when,  the 
joint  giving  way,  such  a  noise  and  crackling  ensued  as  though  the 
whole  of  the  bones  had  been  broken.  Symptomatic  fever  set  in  and 
suppuration  followed,  though  not  to  any  great  extent.  After  nine 
weeks  the  wound  cicatrized,  complete  anchylosis  of  the  ankle  having 
resulted,  though  the  patient  was  able  to  walk  easily.  This  is  the 
first  information  we  have  upon  the  adventurous  practice  of  over- 
coming adherent  attachments  about  joints  by  violent  force,  which 
has  been  introduced  as  a  novelty  within  a  few  years  past  in  ortho- 
paedic practice,  upwards  of  half  a  century  having  elapsed. 

Michselus  of  Marburg,  in  Germany,  is  reported  as  having  treated 
successfully  several  cases  of  talipes  equinus,  in  1809,  by  partially 
severing  the  tendo-Achillis,  being  enabled  thereby  to  bring  the  feet 
at  once  into  a  natural  position.  It  seems,  though,  that  this  would 
be  impossible  without  complete  section  of  the  tendon. 

Benjamin  Bell,  in  remarking  upon  the  generally  received  opinions 
on  the  treatment  of  distorted  limbs,  expressed  himself,  in  1801,  as 
follows :  "  It  has  been  a  prevailing  opinion  among  practitioners  that 
little  advantage  is  to  be  derived  from  any  remedies  that  we  can 
employ  for  distorted  limbs,  and  they  have  seldom  made  any  attempt 
to  cure  them,  in  consequence  of  which  this  branch  of  practice  has 
been  almost  universally  trusted  to  Itinerants  or  to  professed  bone- 
setters."  From  this  the  notorious  bone-setters  may  claim  a  respect- 
able antiquity.  "  In  this,  however,"  says  this  eminent  surgeon,  "  we 
are  wrong.  In  saying  so,  I  can  speak  with  confidence  founded  on 
much  experience.  Having  early  in  life  observed  the  misery  to  which 
patients  were  reduced,  I  was  resolved  to  make  some  attempt  for  the 


34  Orthopjebia. 

relief  of  such  as  might  apply  to  me,  however  small  the  chance 
might  be  of  succeeding ;  and,  in  various  instances,  I  have  had  the 
satisfaction  of  relieving,  and,  in  some  cases,  of  curing  completely 
patients  who  had  been  lame  for  several  years,  and  where  it  was  not 
expected  that  any  thing  could  be  done  for  them.  Various  machines 
have  been  invented  for  the  removal  of  distortions  of  the  spine  by 
pressure.  All  of  these,  however,  do  harm,  and  ought  not  to  be  used. 
It  must  at  once  appear  to  him  who  is  acquainted  with  the  anatomy  of 
the  parts  and  the  nature  of  this  disease,  that  the  displaced  bone  is 
never  to  be  forcibly  pushed  into  its  situation ;  and  if  this  cannot  be 
done,  it  is  evident  that  much  harm  may  ensue  therefrom.  In  all 
distortions  of  the  spine,  it  is  an  object  of  the  first  importance  to 
support  the  head  and  shoulders.  If  this  is  neglected,  the  weight 
of  the  head  tends  almost  constantly  to  increase  the  curvature."* 

This  eminent  surgeon  could  not  have  considered  the  advantages 
to  be  derived  from  lateral  support  applied  to  the  body,  as  a  basis  of 
support  to  the  suspension  of  the  head  by  means  of  a  steel  bar  and 
straps.  It  is  true  that  pressure  upon  a  projecting  portion  of  a 
diseased  spine  is  injurious,  while  that  of  lateral  support  is  of 
inestimable  value  in  the  treatment;  as  it  is  a  preventive  to  motion 
and  attrition  —  the  principal  cause  of  absorption  of  the  impaired 
tissues.  Above  all,  a  well-regulated  regime  is  essential  to  an 
increase  and  diflfusion  of  the  vital  forces  that  ensues  when  rest  to 
the  spine  is  obtained  by  lateral  support  sustaining  the  incumbent 
weight  of  the  parts  above  the  lesion,  thus  permitting  the  patient  to 
take  exercise  in  the  open  air.  The  support  of  the  head  and  should- 
ers is  all  that  is  intimated  by  this  eminent  authority.  The  support 
of  diseased  joints  by  suitably-devised  apparatus  can  only  be  con- 
sidered as  auxiliary  to  other  therapeutic  agencies  in  their  treatment; 
and  then  with  a  favorable  result  only  when  the  patient's  health  can 
be  improved. 

The  remarks  of  Benjamin  Bell  in  regard  to  the  indifference  of 
the  educated  practitioners  of  his  day  as  to  availing  themselves  of 
practical  information  tending  to  the  relief  of  the  deplorable  condi- 
tion of  deformed  persons,  are  equally  applicable  to  the  profession  at 
the  present  day.  It  is  only  a  very  limited  number  of  men,  cele- 
brated for  their  attainments  in  the  medical  profession,  that  have 
devoted  a  moiety  of  their  attention  to  this  most  legitimate  branch 

*  "A  System  of  Surgery,"  7th  ed.,  vol.  VII,  p.  197. 


Defective  Physical  Formation.  35 

of  medical  science.  Hence,  adventurous  treatment  has  been  toler- 
ated by  even  the  most  eminent  in  the  profession  —  as  noted  in  the 
early  history  of  medicine. 

Certain  practical  discoveries  were  made  many  years  before  the 
accepted  introduction  of  the  subcutaneous  division  of  muscles  and 
tendons,  that  should  have  invited  earlier  attention  to  this  invaluable 
practice.  John  Hunter,  in  his  '' Treatise  on  the  Blood,  Inflamma- 
tion and  Gun-shot  "Wounds,"  published  in  the  year  1794,  narrates 
certain  physiological  discoveries  that  should  have  prompted  the  sub- 
cutaneous operation  for  the  relief  of  contracted  muscles  and  tend- 
ons in  cases  of  irreducible  dislocations  presenting  in  accidental 
injuries,  if  not  for  the  cure  of  congenital  deformities  or  the  sequence 
either  of  infantile  paralysis  or  chronic  disease  of  the  joints.  It  is 
patent  that,  if  it  had  been  made  available  in  the  one  instance,  it 
would  certainly  be  equally  applicable  in  others. 

This  eminent  surgeon  says:  "The  injuries  done  to  the  sound 
parts  I  shall  divide  into  two  descriptions,  according  to  the  effects 
of  the  accident.  The  first  kind  comprises  those  in  which  the 
injured  parts  do  not  communicate  externally;  as  concussions  of  the 
whole  body  or  of  particular  parts,  strains,  bruises,  and  simple  frac- 
tures, either  of  the  bone  or  tendon,  which  form  a  large  proportion. 
The  second  consists  of  those  which  have  an  external  communication, 
comprehending  wounds  of  all  kinds,  and  compound  fractures. 

"Bruises  which  have  destroyed  the  life  of  the  part  may  be  con- 
sidered as  a  third  division,  partaking  at  the  beginning  of  the  nature 
of  the  first,  but  finally  terminating  like  the  second. 

"The  injuries  of  the  first  division,  in  which  the  parts  do  not 
communicate  externally,  are  hut  seldom  suhject  to  inflammatory  pro- 
cess ;  loliile  those,  of  the  second,  commonly,  are  loth  inflammatory  and 
sujjpurative." 

To  Mr.  Hunter  must  be  aAvarded  the  merit  of  being  the  first  to 
invite  attention  to  the  true  pathological  sequence  of  injuries,  as 
well  as  ideas  suggestive  of  subcutaneous  surgery,  as  it  is  known 
that  he  performed  successful  operations  upon  tendons  of  dogs, 
which  he  severed  subcutaneously.  He,  at  different  periods,  killed 
the  animals  operated  upon,  finding  in  every  case  the  tendons  he  had 
divided  subcutaneously  firmly  united.  These  experiments  were  per- 
formed in  the  year  1767. 

It  is  truly  remarkable  that  forty-nine  years  should  have  elapsed 
from  the  time  of  Hunter's  experiments  upon  quadrupeds  before 


36  Or  thop^dia. 

Delpech  performed  the  operation  upon  the  tendo-Achillis  of  man, 
which,  however,  proved  so  unfavorable  as  to  deter  him  from  further 
effort.  That  he  was  impressed  with  the  essentials  to  success  must 
be  conceded,  as  stated  in  his  work  "  L'Orthomorphie,"  published 
some  thirteen  years  after  his  unsuccessful  operation  of  making  a  lon- 
gitudinal incision  of  one  inch  on  either  side  of  the  tendo-Achillis, 
thus  leaving  a  portion  of  the  skin  over  the  tendon  when  severed. 
This  procedure  may  be  considered  as  premising  the  subcutaneous 
severing  of  tendons  for  the  relief  of  contorted  muscles.  This 
occurred  in  1816.  That  the  one  failure  should  have  deterred  so 
noted  a  surgeon  is  extraordinary  and  almost  incomprehensible.  It 
should  have  induced  sufficient  courage  and  desire  to  prompt  at 
least  another  effort ;  and,  in  the  event  of  that  proving  successful 
(which  it  undoubtedly  would  have  done),  he  would  have  been  placed 
on  the  highest  pinnacle  of  fame.  But  this  was  to  be  left  for  the 
eminent  Stromeyer,  of  Hanover,  who  availed  himself  of  the  rules 
laid  down  by  Delpech,  which  were  truly  worthy  of  consideration, 
and  inaugurated  a  series  of  practical  experiments  which  resulted  in 
a  decided  success. 

Stromeyer  performed  his  first  operation  on  the  tendo-Achilles  in 
the  year  1831,  and  published  an  account  of  the  subsequent  results 
of  treatment  in  the  years  1833  and  1834,  thus  furnishing  the  initial 
of  scientific  tenotomy  —  the  success  in  this  new  treatment  being  one 
of  the  greatest  achievements  in  modern  surgery,  and  so  considered 
by  all  recognized  authority  in  the  medical  profession. 

There  appears  to  have  been  for  several  years  among  eminent  prac- 
titioners a  reluctance  to  countenance  or  endorse  the  great  discovery 
of  Stromeyer,  or  rather  a  disposition  to  cast  a  doubt  upon  the  verity 
of  his  success ;  but  truth  again  prevailed,  to  the  benefit  of  mankind, 
when  the  enterprising  Dieffenbach,  of  Berlin,  entered  as  a  laborer 
in  this  field  of  new  discovery,  thereby  inciting  others  to  do  the 
same. 

In  1835,  Duval,  of  Paris,  was  the  first  to  sever,  subcutaneously, 
the  tendo-Achillis  in  that  city ;  then  Bauvier,  and,  about  the  same 
time,  Pauli,  in  Grermany,  and  Jules  Gfuerin,  of  Paris  —  the  latter 
being  a  most  indefatigable  investigator  and  daring  operator.  During 
this  period.  Bonnet,  of  Lyons,  and  Scoutetten,  of  Strasburg,  entered 
with  great  energy  into  the  scientific  treatment  of  club-foot;  and,  in 
less  than  five  yearfe,  sevieral  hundred  cases  of,  not  only  club-feet,  but 
of  all  superficial  contracted  muscles  in  all  parts  of  the  body  and 


Defective  Physical  Formation.  37 

limbs  producing  deformity,  were  severed  subcutaneously.  Many  of 
the  deformed  were  thus  restored  to  normal  conditions,  with  scarcely 
an  unfavorable  case  resulting  from  the  practice,  placing  opposition 
at  defiance ;  for  the  scrutiny  of  the  most  eminent  in  the  profes- 
sion, both  at  home  and  abroad,  was  brought  to  bear  upon  these 
adventurous  practitioners,  as  they  were  considered;  and,  if  there  had 
been  a  permanent  injury  sustained  by  a  patient,  or  any  entirely 
unsuccessful  case,  they  would  have  been  noted  and  exposed,  so 
strong  was  the  opposition  and  so  severe  the  criticism. 

Mr.  Whipple,  of  Plymouth,  England,  informed  Mr.  W.  Adams,  of 
London,  that  he  severed  the  teudo-Achillis  in  May,  1836.  This 
was  the  first  operation  of  the  kind  known  to  have  been  performed 
in  England.  Dr.  Little,  whose  account  is  exceedingly  interesting, 
divided  the  tendo-Achillis  in  the  city  of  London,  February  20, 1837. 
The  history  is  given  by  Mr.  W.  Adams  in  his  Essay ;  to  which  was 
awarded  the  Jacksonian  prize  of  1864,  by  the  Eoyal  College  of 
Surgeons,  London. 

In  1837  the  first  publication  was  given  of  the  operation  having 
been  performed  in  this  country  by  the  subcutaneous  severing  of  the 
tendo-Achillis  and  other  tendons  for  the  relief  of  club-foot.  This 
was  by  William  Detmold,  M.  D.,  since  Professor  of  Orthopaedic 
Surgery,  who  in  this  year  arrived  in  New  York  city  from  Germany. 
He  treated  several  cases  of  club-feet  by  the  preparatory  operation 
of  severing  the  tendo-Achillis  by  the  new  method,  of  which  he  pub- 
lished the  account  in  the  "  Medical  Journal "  of  Philadelphia.  Pro- 
fessor Nathan  E.  Smith,  of  the  University  Medical  College  of  Mary- 
land, states  that  he  performed  the  operation  previous  to  this  date ; 
but,  as  a  report  of  the  case  was  not  published,  the  credit  is  due  to 
Dr.  Detmold.  This  enterprising  surgeon  and  teacher  stated,  in  a 
course  of  lectures,  delivered  in  1842,  that  he  had  operated  in  about 
four  hundred  cases  of  club-foot.  Many  other  surgeons,  during  this 
period  of  five  years,  tested  the  new  operation,  but  unfortunately 
failed,  in  extraordinary  cases,  to  realize  their  expectations,  because 
of  their  inexperience  in  the  subsequent  treatment.  Hence,  doubt 
and  indifference  has  limited  the  practice  to  a  few  of  the  energetic 
and  more  enterprising  practitioners,  who,  availing  themselves  of 
their  experience  in  devising  variously  modified  apparatus,  have 
been  more  successful.  This  has,  however,  tended  to  each  practi- 
tioner's lauding  his  own  special  method  of  treatment  in  the  redress- 
ing of  the  deformity.     The   neglect,  unfortunately,  to  divide  the 


38  Orthopjebia. 

tendons  of  unyielding  shortened  muscles,  tense  fascia,  and,  in  some 
cases,  ligaments,  when,  if  premised  by  careful  perseverance  in  the 
application  of  various  devices,  manipulation,  and  the  skilfully 
applied  roller,  they  would  have  restored  nearly  all  cases  of  this 
deformity  to  normal  appearance. 

And  yet  it  is  much  to  be  lamented  that  many  inexperienced  in 
orthopa?dic  practice  attempt  the  ti'eatment  of  club-foot,  relying 
mainly  on  the  operation,  to  the  great  discouragement  of  the  patient 
—  the  tendons  having,  in  numerous  instances,  been  severed  several 
times,  and  the  case  finally  abandoned,  after  having  inflicted  much 
suffering  upon  the  unfortunate  cripple,  who  could  have  been  easily 
cured  by  skilful  treatment.  These  are  about  all  the  patients  who 
are  suffering  from  injudicious  advice  for  this  complaint  after  treat- 
ment, and  not  cured  at  the  present  day ;  except  the  very  indigent, 
who  could  not  heretofore  avail  themselves  of  the  opportunities  for 
treatment  now  existing ;  and  those  living  in  distant  and  sparsely 
inhabited  parts  of  the  country,  where  it  is  impossible  for  the 
patients  to  be  supplied  with  proper  appliances,  and  daily  attendance 
from  persons  skilled  in  the  manipulation  and  bandaging  of  their 
limbs ;  the  latter  auxiliaries  being  as  essential  to  successful  treat- 
ment ^s  the  severing  of  constricted  tissues;  and  in  many  cases  of 
slight  deformity  of  the  feet,  skilful,  persevering  manipulation  and 
bandaging  will  restore  them  to  a  normal  condition. 


CHAPTER    11. 

IMPAIRMENT  OF  TISSUES  RESULTING  IN  CONTORTIONS. 

Contortion  of  body  or  limb  the  result  of  impaired  integrity  of  the  fibroua 
tissues. —  Paralysis  of  the  extensor  muscles. —  Under  cerebro-spinal  irritation, 
the  muscles  not  entirely  under  the  control  of  the  will. —  Various  forms  of 
Contortion  of  the  Feet. —  Talipes  varus,  talipes  valgus,  talipes  equinus, 
and  talipes  calcaneus,  their  definition. —  Non-congenital  contortions  exceed  the 
congenital  in  the  proportion  of  three  to  one. —  Talipes  varus,  valgus  and  cal- 
caneus generally  take  place  during  intra-uterine  development. —  Conforma- 
tion OF  THE  Foot. —  Difference  of  construction  between  the  human  foot  and 
that  of  the  bear. —  The  articulation  and  elasticity  of  the  foot,  and  its  relation 
to  the  leg. —  The  malleolus  internus  and  externus. —  Early  diagnosis  of  ten- 
dency to  deformity  of  the  highest  importance  to  patients. —  A  thorough 
knowledge  of  anatomy  necessary  to  a  correct  diagnosis. —  The  outer  contour 
of  the  foot  in  its  normal  condition. —  Abnormal  Position  op  Bones,  Liga- 
ments AND  Muscles  in  Talipes  Varus. —  Luxation  invariably  found. —  The 
Astragalus  least  liable  to  deviation,  especially  in  cases  of  dental  paralysis. — 
Change  of  position  of  the  cuboid  bone. —  Marked  deviation  of  the  os  calcis, 
and  the  relative  articulating  surfaces. —  Position  of  the  cuneiform,  metatarsal, 
and  phalangeal  bones. —  Diminution  of  the  plantar  aponeurosis. —  Change  in 
the  normal  relation  of  the  muscles. —  In  extreme  cases,  the  peronei  paralyzed. — 
Duverney's  assertion  that  the  loss  of  contractile  power  is  a  primary  cause  of 
talipes  varus. —  Tendencies  to  Aberration  op  Form. —  Yielding  of  the  liga- 
ments tends  to  produce  varus. —  Impairment  of  the  normal  conformation  of  the 
arch. —  Diagnosis  of  congenital  varus. —  Difference  between  congenital  and 
non-congenital  varus. —  Talipes  valgus,  its  leading  features. —  Talipes  equinus, 
its  modifications  and  chief  features. —  Talipes  calcaneus,  differences  between 
that  variety  and  the  preceding. —  Talipes  calcaneus  occasionally  attributable  to 
careless  treatment  in  the  subdivision  of  the  tendo-Achilles. —  Views  of  Wil- 
liam Adams  on  talipes  equinus. —  His  diagnosis  of  the  affection. — The  liga- 
ments subject  to  structural  impairment. —  The  Condition  op  the  Muscles  in 
Talipes  Varus. —  If  proper  remedial  measures  are  at  once  taken,  a  perfect 
and  simultaneous  cure  results  with  the  growth  of  the  body. —  Position  of  the 
tibiales  posticus  and  anterior  tendons  in  severe  cases. —  Influence  of  Liga- 
ments IN  Talipes  Varus. —  Method  of  obtaining  accurate  diagnosis  of  struc- 
ture of  ligaments. —  Infantile  paralysis  generally  the  cause  of  non-congenital 
contortion  of  the  feet. —  Permanent  deformity  arising  from  compression  of  the 
foot,  as  in  the  Chinese. —  The  plantar  fascia. —  Condition  of  the  legs  in  cases 
of  prolonged  contortion. —  Contortion  arising  from  Paralysis. —  With 
proper  treatment,  care  and  perseverance,  restoration  to  normal  power  almost 


40  Orthop^sdia. 

certain. —  Suegical  TKEATiiEST  OF  Contorted  Feet. —  Special  study  and 
experience  on  the  part  of  the  practitioner  necessary  to  ensure  a  successful 
result  in  the  treatment  of  contortions  of  the  body  or  limbs. —  Preparatory 
Steps  in  Treatment. —  Description  of  dressings. —  Preparation  prior  to  opera- 
tion—  Means  of  restoring  Foot  to  normal  Form:. —  Course  of  procedure 
after  operation. —  Treatment  of  patient  after  successive  paralytic  seizures. — 
Suppuration  of  tendon  occasionally  supervening  in  cases  of  strumous  dia- 
thesis.—  Severing  the  plantar  fascia. —  The  treatment  necessary  in  such 
cases. —  R.  M.  Tamplin's  testimony  as  to  the  danger  of  puncturing  an  artery  in' 
tenotomy. —  Manipulation  essential  as  an  adjuvant. —  Application  of  the  Scarpa 
shoe  beneficial. —  Congenital  club-foot  curable  by  perseverance  in  proper  treat- 
ment.—  Third  stage  of  TAiiiPES  varus. —  The  treatment. —  On  severing  the 
posterior  tibial  tendon. —  Mies  and  William  Adams  on  severance  of  the  ten- 
don.—  Continued  extension. —  Treatment  of  punctured  arteries. —  Sub- 
cutaneous severance  of  tendons. —  Firm  coagulation  of  the  blood  an  incident 
in  the  diagnosis. —  Tenotomy  knives,  description  of. 


CoxTOETiox  of  body  or  limb  is  the  result  of  impaired  integrity 
of  the  fibrous  tissues.  The  ligaments  are  the  primary  sustaining 
media  of  the  skeleton  when  in  their  normal  condition ;  and  by 
their  elasticity  are  made  subservient  in  a  limited  degree  to  the  action 
of  the  muscles.  Conjointly,  they  maintain  all  that  pertains  to  the 
normal  form  essential  to  the  movement  of  the  body  and  limbs,  con- 
stituting, with  the  cerebro-spinal  functions,  the  locomotive  condi- 
tion of  the  animal  economy.  From  this  view  of  the  animal  system 
we  will  consider  the  diversions  that  tend  to  contortions. 

Existing  contortions,  thus  considered,  would  indicate  a  loss  of 
integrity  in  the  ligaments  without  regard  to  the  inimical  cause,  as 
it  is  impossible  for  a  permanent  contortion  of  the  skeleton  to  take 
place  without  a  yielding  of  the  ligaments  to  the  unfavorable  influ- 
ence that  tends  to  the  final  contortion.  The  yielding  of  ligaments 
will  impair  normal  muscular  antagonism  to  the  extent  of  the  loss 
of  the  essential  equilibrium  of  action  that  sustains  the  form,  and 
thus  contortion  is  induced  (from  that  of  a  slight  impairment  to  that 
of  an  almost  entire  degeneration)  from  the  increasing  loss  of  normal 
integrity  of  the  ligaments. 

A  paralytic  seizure  of  the  extensor  muscles  of  a  limb  impairs 
their  muscular  tension,  and  thus  permits  the  flexors  to  shorten 
and  remain  quiescent.  Long-continued  unfavorable  position,  from 
whatever  cause,  tends  to  a  similar  result.     These  inimical  influences 


Impairment  of  Tissues  Resulting  in  Contortions.    41 

impair  the  muscular  tissues  primarily,  and  the  ligaments  second- 
arily and  vice  versa. 

Cerebro-spinal  irritation  influences  the  normal  motor-power  of 
the  muscles,  producing  the  most  intractable  cases  of  congenital  and 
non-congenital  contortions.  The  muscles,  under  this  abnormal 
influence,  are  not  subject  to  the  entire  control  of  the  will,  but  only 
partially  so,  and  by  a  spasmodic  movement,  the  contortion  yielding 
for  the  time  to  slowly  increasing  force  —  in  many  instances  to  nor- 
mal force.  But  from  every  effort  of  the  will  to  progressive  move- 
ment, the  spasmodic  disposition  is  exerted  to  a  resistance  terminat- 
ing in  contortion.  These  remarks  as  to  the  conditions  attending 
the  impairment  of  tissues  resulting  in  contortion,  though  neces- 
sarily brief,  are  essentially  requisite  to  the  proper  consideration  of 
the  several  varieties  of  contortions  of  the  body  and  limbs. 


VAEIOUS    FORMS    OF    CONTORTION"    OF   THE   FEET. 

Contortions  of  the  feet  appear  to  be  the  most  numerous  of  all  to 
which  the  animal  conformation  is  subject;  the  non-congenital 
exceeding  the  congenital  three  to  one,  according  to  the  statement 
of  Mr.  W.  Adams,  which  statement  agrees  with  our  own  observation. 

The  following  four  designations  constitute  the  recognized  varie- 
ties of  contortions  of  the  feet : 

1st.  Talipes  varus :  inversion  of  the  anterior  portion  of  the  foot, 
with  elevation  of  the  heel. 

2nd.  Talipes  valgus  :  eversion  of  the  anterior  portion  of  the  foot. 
Of  this  we  have  two  forms :  first,  a  depression  of  the  heel ;  second, 
an  elevation  of  the  heel. 

3d.  Talipes  equinus :  elevation  of  the  heel,  and  extension  of  the  foot. 

4th.  Tali2Jes  calcaneus :  depression  of  the  heel.  Of  this  there  are 
four  intermediate  forms  :  first,  the  foot  is  slightly  inverted ;  second, 
the  foot  everted  from  slight  yielding  of  the  plantar  tissue ;  third, 
an  approximation  of  the  heel  to  the  anterior  of  the  foot  from  slight 
contraction  of  the  plantar  tissues ;  fourtli,  a  decided  eversion  and 
elevation  of  the  anterior  portion  of  the  foot.  All  these  may  be 
included  as  varieties,  though  the  classification  is  of  but  little  advan- 
tage in  the  practical  treatment.  As  such  cases  present,  they  will 
require  to  be  treated  according  to  the  indications  derived  from  a 
general  knowledge  of  the  subject. 


42 


Orthopjebta. 


The  first,  second  and  fourth  of  these  varieties  of  contortion  of  the 
feet,  are  those  generally  recognized  as  having  taken  place  during 
intra-uterine  development,  and  some  of  them  in  the  early  formative 
stage.  Of  the  latter,  the  bones  have  conformed  in  shape  to  the 
contorted  condition;  rendering  it  almost  impossible  to  redress  the 
deformity.  Fortunately,  there  are  but  few  such  cases.  Of  this  con- 
dition of  contorted  feet,  we  have  only  had  to  treat  about  eight 
extreme  cases  in  thirty  years,  of  orthopaedic  practice  —  the  patients 
being  much  improved  after  persistent  effort;  the  instep  remaining 
prominent  and  the  feet  short  and  cramped  in  appearance.  However 
long  this  continued  course  of  perseverance  in  treatment  may  be. 
required,  if  improvement  is  progression,  the  effort  is  remunerative 
in  the  relief  afforded  the  patient  in  his  rescue  from  a  wearisome, 
dependent,  and  despondent  existence,  even  though  the  foot  may 
not  be  entirely  restored  to  its  normal  form. 


COXFOKMATIOX    OF   THE    FOOT. 

In  order  to  obtain  a  proper  knowledge  of  the  contortions  of  the 
feet,  attention  must  be  given  to  the  conformation  of  the  foot  in  a 
normal  condition,  and  for  this 
purpose  we  give  the  following 
wood-cut  (Fig.  9),  represent- 
ing the  skeleton  of  the  human 
foot  in  ordinary  form,  and  its 
relation  to  the  leg,  shown  by 
an  outline  of  the  surrounding 
integument.  The  tibia  and 
fibula,  being  separate,  present 
more  clearly  the  tibio-tarsal 
relation. 

A  line  drawn  from  a  central 
point  of  the  distal  portion  of 
the  OS  calcis  curving  to  a  cen- 
tral point  of  the  great  toe, 
bounding  the  outer  side  of  the 
foot,  nearly  describes  a  semi- 
circle, and  both  feet  placed 
together  completes  the  circle. 


In    ordinarv   locomotion    the  body 


Impairment  of  Tissues  Resulting  in  Contortions.    43 

is  sustained  by  a  complete  circular  bearing  of  the  outer  mar- 
gins of  the  feet,  limited  in  breadth  of  base,  being  totally  different 
from  the  plantigrade  feet  of  the  bear  —  the  whole  surface  of  his 
feet  being  planted  at  every  step.  In  the  foot  of  man  the  step  is 
accomplished  by  the  heel  touching  the  ground  first,  the  body 
advancing  and  concentrating  the  force  upon  the  metatarso- 
phalangeal bearing  —  the  great  toe  mainly  governing  the  regular 
movement,  which  is  completed  with  elastic  force,  tending  to  facili- 
tate the  succeeding  step.  The  plantar  surface  of  the  foot  of  man 
does  not  leave  an  impress  upon  the  ground,  as  does  that  of  the  bear 
or  lower  grade  of  animals,  which,  unlike  man,  are  not  subject  or 
liable  to  lateral  deviation  of  the  feet. 

This  invites  our  attention  to  the  articulation  and  elasticity  of  the 
human  foot,  and  its  relation  to  the  leg.  The  tibia  rests  upon  the 
rounded  surface  of  the  astragalus,  and  is  maintained  laterally  by 
the  malleola,  internus  and  externus,  sustained  by  strong  ligaments 
attached  to  the  os  calcis.  The  lower  portion  of  the  malleolus 
internus,  in  an  ordinary  sized  man,  is  elevated  from  the  ground 
about  three  inches,  and  the  externus  about  tivo  and  a  half ;  admit- 
ting of  lateral  deviation  and  stress  upon  the  sustaining  ligaments 
that  are  liable  to  elongation.  In  the  foot  of  the  bear  the  malleola 
are  only  about  an  inch  above  the  plantar  surface,  and  are  of  equal 
elevation;  and  this  animal,  being  a  quadruped,  does  not  require  the 
elasticity  of  the  biped,  man,  to  enable  him  to  walk.  Hence  the  dif- 
ference between  the  two  plantigrade  animals,  the  latter  not  being 
subject  to  contortion  of  the  feet. 

Unfavorable  impressions  during  gestation,  as  we  have  before 
stated,  impair  the  articulatory  relations  of  the  bones  in  the  foot  to 
an  abnormal  condition  of  increasing  tendency.  The  slightest 
yielding  of  any  point  gives  direction  to  the  subsequent  condition, 
definable  as  a  variety  of  contortion  bearing  a  special  designation. 
An  early  diagnosis  of  tendencies  to  deformity  of  the  feet  is  of  much 
importance  to  the  patient,  and  a  prompt  decision  is  required  from 
the  surgeon.  To  obtain  the  requisite  practical  ability  for  this,  a 
thorough  knowledge  of  anatomy  is  required  as  well  as  careful  clini- 
cal observation —  the  former,  being  a  branch  of  surgical  science, 
must  be  well  studied  in  order  to  obtain  a  practical  insight  into  the 
intricacies  of  orthopaedic  surgery.  The  outer  contour  of  the  foot 
in  its  normal  condition  is  first  to  be  carefully  considered.  The  foot 
presents  an  elastic  arch  of  unequal  lengths  of  span,  diminishing 


44 


Orthop^dia. 


laterally.  This  is  not  so  apparent  as  is  really  the  ease.  On  the 
inner  face,  the  arch  of  the  skeleton  is  clearly  defined;  on  the 
outer,  the  yielding  integument  fills  the  Figs.KSanan. 

shortened  arch  to  a  level  with  the  bear- 
ing of  the  foot.  This  will  be  more  clearly 
observed  by  reference  to  the  skeleton 
of  the  foot  as  shown  in  Figures  10,  11, 
and  13. 

Figure  10  represents  the  inner  face  of 
the  arch  ;  A  and  B  the  points  of  bearing ; 
C  the  outline  of  the  integument  of  the 
decreased  arch. 

Figure  11  represents  the  outer  face  of  the  arch ;    A  and  B  the 
points  of  bearing ;  C  the  integument  sustaining  the  arch. 

This  diminishing  of  the  span  laterally  pre- 
sents a  curvilinear  face  to  that  portion  of 
plantar  surface  constituting  a  transverse  as 
well  as  a  longitudinal  arch ;  see  dotted  line 
in  fig.  11. 

The  outer  face  of  the  arch  is  more  distinct- 
ly observed  when  the  individual  is  balancing 
on  the  anterior  portion  of  the  foot. 

Figure  12  :  A  the  posterior  portion  of  the 
foot    elevated ;   C    the  point  pressed  upon ; 


Fig.  12. 


B  the  defined  arch. 


ABJifORMAL    POSITION"     OF     BONES,     LIGAMENTS    AND     MUSCLES    IN 

TALIPES   VARUS. 

Among  all  the  articular  changes  that  take  place  in  the  bones,  in 
cases  of  varus,  and  of  the  most  extreme  forms,  they  are  never  found 
to  be  completely  luxated,  there  being  only  a  deviation,  with  partial 
separation  of  the  articular  surfaces  from  the  yielding  of  ligaments 
upon  the  outer  portion  of  the  foot,  and  the  fixed  shortened  condi- 
tion on  the  incurvation,  and,  in  some  cases,  adaptation  of  the  bones 
in  development  to  the  abnormal  conformation. 

The  Astragalus,  of  all  the  bones  of  the  foot,  deviates  the  least  in 
oases  of  varus,  other  than  its  relation  to  the  tibia,  admitting  of  lim- 
ited lateral  deviation,  and  more  especially  in  cases  resulting  from 
dental  paralysis. 


Impairment  of  Tissues  Resulting  in  Contortions.    45 

The  anterior  articulating  surface,  because  of  its  normal  position, 
presents  a  protuberance  upon  the  dorsum  of  the  foot,  and  is  ren- 
dered thus  prominent  by  the  rotation  of  the  navicular  bone  inward 
and  obliquely  across  the  extremity  of  the  astragalus  to  a  close  con- 
tact with  the  internal  malleolus. 

The  cuboid  bone  becomes  changed  from  its  normal  position,  being 
separated  from  the  lesser  apophysis  of  the  os  calcis  and  rotated  upon 
its  lesser  axis.  It  is  chiefly  upon  this  bone  that  the  weight  of  the 
body  is  borne  when  walking,  and  limited  to  the  bursse  that  is  formed 
over  this  bone,  as  before  described. 

The  OS  calcis  presents  the  most  decided  deviation  of  any  of  the 
bones  of  the  foot,  when  complete  varus  has  supervened.  It  is  so 
completely  rotated  upon  its  lesser  axis  that  its  posterior  tuberosity 
is  in  contact  with  the  internal  malleolus,  and  drawn  so  forcibly 
upward  by  the  tendo-Achillis  that  it  is  scarcely  definable,  the  ante- 
rior articulating  portion  being  equally  depressed,  thus  making  a 
very  decided  cha.nge  in  the  relative  articulating  surfaces  with  that 
of  the  astragalus. 

In  conformity  with  these  changes  we  find  the  three  cuneiform, 
the  metatarsal  and  the  phalangeal  bones  all  directed  upward  and 
inward,  tending  from  a  horizontal  to  a  vertical  position.  I.'he  liga- 
ments that  sustain  the  bones  in  this  position  are  greatly  impaired, 
shortened  or  lengthened  in  conformity  to  the  malposition  of  the 
bones.  In  varus,  all  those  on  the  inner  side  of  the  foot  are  tense 
and  firm,  though  on  the  outer  side  some  are  greatly  elongated, 
especially  at  the  articulation  of  the  cuboid  with  the  os  calcis.  The 
flantar  ajjoneurosis,  in  exti-eme  cases,  unless  severed,  will  be  found 
diminished  in  breadth  and  exceedingly  tense,  being  an  almost  insu- 
perable obstacle  in  the  redressing  of  the  contortion  of  the  foot. 

As  to  the  muscles,  their  normal  relations  are  greatly  changed. 
The  gastrocnemii  solei  and  plantares  are  much  shortened,  and  the 
tendons  partially  separated  in  the  common  sheath  near  their  inser- 
tion, their  shortened  condition  impairing  other  muscles,  from  con- 
tinued stress,  and  are  the  principal  muscles  implicated  in  producing 
several  varieties  of  contortion  of  the  foot.  In  extreme  cases  of 
varus,  the  two  tibials,  the  flexor  longus  of  the  toes,  and  the  adductors 
all  contribute  to  the  contortion.  By  the  shortened  condition  of 
these  muscles  the  peronei  are  so  much  impaired  in  tone  as  to  nearly 
lose  their  power  of  contraction  and  to  be  in  a  paralytic  condition. 
Duvernev  and  others  consider  the  loss  of  contractile  power  in  the 


46 


OrTHOPjEBIA, 


peronei  miTScles  as  a  primary  cause  of  yarns.  That  varus  has  been 
the  result  of  this  derangement  cannot  be  doubted,  nor  tliat  a  short- 
ening of  the  flexor  tendon  has  produced  a  similar  result  from  a 
continual  extension  of  those  muscles.  In  either  case,  the  muscular 
equilibrium  has  been  impaired,  and  may  have  been  so  impaired,  by 
the  extraordinary  yielding  of  the  ligaments.  Hence  these  abnormal 
conditions  of  muscles  or  ligaments  tend  to  contortion  of  the  feet. 


FiQ.  13. 


TEXDEXCIES   TO    ABEKEATIOX   OF   TOEM. 

It  is  the  yielding  of  the  ligaments  which  sustain  this  outer  por- 
tion of  the  arch  that  tends  to  produce  varus.  The  normal  bearings 
are  relieved  by  the  settling  down  of  the  central  portion  of  the  outer 
margin  of  the  foot,  inclining  the  an- 
terior portion  inward. 

Figure  13,  the  skeleton  of  the  foot; 
A,  the  elongated  ligaments  that  sus- 
tain the  metatarsal  and  cuboid  bones 
in  normal  relation,  and  also  the  liga-  ^ 

ment  that  sustains  the  os  calcis  and  cuboid. 

This  yielding  of  the  ligaments  that  sustain  the  outer  arch  of  the 
skeleton  of  the  foot  impairs  the  normal  conformation  of  the  arch  ; 
not  apparent,  however,  to  a  casual  observer.  The  base  of  support  is 
now  concentrated  upon  the  center  of  what  constituted  the  arch  of 
the  outer  margin  of  the  foot,  the  two  distant  points  of  support  hav- 
ing yielded,  and  gradually  limited  the  base  of  Fig.v^. 
support  to  a  very  small  space. 

Figure  14.    A  and  B  represent  the  central  line     pi 
of  separation ;  C  the  articulating  surfaces  of  the   '^\\        a 
astragalus  and  os  calcis,  changing  position  from  t^^,*^    \ 
the  scaphoid  and  the  cuboid.  c-c^  ;~^  .■-v; 

The  ligaments  yield  to  an  extraordinary  de- 
gree, permitting  certain  muscles  to  shorten  and 
become  impaired  in   their   integrity  from    the  -^ 

abnormal  quiescent  condition  tending  to  the  partial  arrest  of  nutri- 
tion. 

Congenital  varus  usually  presents  but  a  slight  curving  inward  of 
the  child's  foot  before  it  has  walked.     The  curving  inward  of  the 


Impairment  of  Tissues  Resulting  in  Contortions.    47 


anterior  and  posterior  portions  of  the  foot  would  seem  to  be  the 
result    of 


pressure     from 
Figs.  15  and  16. 


the 


weight    of    the    body    after    the 
child   has    commenced   Avalking 
ujDou  the  limited  abnormal  base. 
Figures  15  and  16  present  the 
congenital  varus  before  walking. 
JSTon-congenital  talipes  varus  dif- 
ers  in  the  first  stage  from  that  of 
congenital,  because  of  the  weight 
upon  the  feet  from  the  commence- 
ment of  the  difficulty.     The  anterior  portion  of  the  foot  in  either 
case  inclines  inward,   and  in  walking,  only  one-third  of  the  outer 
Figs.  17  and  18.  margin  touches  the  ground.  First, 

^  the  heel  being  elevated,  giving 
thereby  to  the  patients  an  awk- 
ward appearance  in  walking ;  they 
are  then  said  to  be  pigeon-toed, 
and  finally  club-footed,  when  de- 
formed as  seen  in  Figs.  17  and  18. 
The  eversion  of  the  foot,  termed 
talipes  valgus,  is  attended  with 
much  less  contortion  than  varus. 
Valgus  arises  from  a  yielding  of  the 
inner  margin  of  the  arch ;  tending  only  to  a  flattening  and  spread- 
ing of  the  parts  laterally,  as  it  is  impossible  for  the  outer  margin 
to  turn  upward.     The  os  calcis,  in  some  cases,  becomes  considerably 

elevated  from  shortening 
of  the  muscles.  Figures 
19  and  20  represent  this 
condition  of  the  foot. 

This   distortion  i-epre- 
sents  the  flat  or  splay  foot. 
Of  the  contortions   of 
the  skeleton  of  the  foot,  va- 
rus and  valgus  represent 
the  type  of  all  the  sev- 
eral varieties  included  un- 
der the  head  of  club-foot. 
h\  talipes  equinus  there  is  but  a  very  limited  change  in  the  skel- 
eton of  the  foot :  the  principal  concentration  of  force  being  upon 


Figs.  19  and  20. 


48 


Orthop^dia. 


the  metatarso-jDlialangeal  bearing — allowing  the  toes  to  conform  to 
the  elevation  of  the  posterior  portion  of  the  foot,  as  represented  in 
Figures   21   and  22,      A  Figs.2\and'^. 

slight  inclination  inwards 
entitles  the  case  to  be  de- 
signated equino-varus,  or 
a  reverse  change,  equino- 
valgus.  Thus  the  several 
variations  have  obtained 
their  designation. 

Talipes  calcaneus  pre- 
sents a  very  decided 
change  in  the  skeleton. 
The  proximal  end  of  the  os  calcis  is  elevated  to  the  contracting  of 
the  longitudinal  arch  of  the  foot,  the  heel  becoming  the  most  deter- 
mined point  of  bearing,  and  in  some  cases  sustains  or  is  constituted 
the  only  point  of  bearing.  In  this  we  have  a  shortening  of  the 
ligament  and  aponeurosis  of  the  plantar  surface  of  the  foot  as  a 
consecutive  result  of  a  yielding  mainly  of  the  gastrocnemii  plantar 
and  soleus  muscles.  This  is  one  of  the  abnormal  conditions  of  the 
fcBtus,  and  has  resulted  also  in  some  cases  from  the  subcutaneous 
division  of  the  tendo-Achillis  — a  truly 
lamentable  occurrence  that  can  only  be 
attributed  to  a  careless  subsequent  treat- 
ment. Figure  23  fully  represents  this  con- 
dition in  a  mild  form.  That  the  liga- 
ments are  subjected  to  unfavorable 
changes  is  generally  admitted ;  that  they 
may  be  impaired  by  posture  and  become 
permanently  shortened,  or,  by  loss  of 
tenacity,  lengthened;  in  this  way  causing 
an  alteration  in  the  form  of  the  skeleton 
to  the  impairment  of  the  equilibrium  of  normal  force  in  the  mus- 
cles is  likewise  generally  admitted. 

Mr.  William  Adams,  on  page  85  of  his  prize  essay,  referring  more 
especially  to  talipes-equinus,  says:  "  The  ligamentous  structures  in 
front  of  the  ankle-joint  and  on  the  dorsal  aspect  of  the  foot, 
especially  the  ligament  between  the  astragalus  and  navicular  bone, 
are  found  to  be  elongated  in  proportion  to  the  degree  and  duration 
of  the  deformity;  while  those  on   the  plantar  aspect  of  the  foot  are 


mo.  23. 


Impairment  of  Tissues  Resulting  in  Contortions.    49 

contracted  and  shortened  to  a  corresponding  extent.  The  struc- 
tural shortening  and  adaptation  of  the  ligaments  in  the  sole  of  the 
foot  connecting  the  tarsal  bones  —  especially  the  calcareo-cuhoid 
and  calcareo-scaphoid  ligaments  and  the  plantar  fascia  —  always 
correspond  to  the  severity  and  duration  of  the  deformity,  and  offer 
the  greatest  resistance  to  its  removal.  The  lateral  ligaments  of  the 
ankle-joint  are  also  elongated  in  their  anterior  portions,  and  con- 
tracted at  their  posterior  borders.  The  posterior  ligaments  of  the 
ankle-joint  become  structurally  shortened  in  adaptation  to  the 
altered  relations  of  the  os  calcis  and  tibia,  which,  in  severe  cases, 
are  in  contact  at  the  ankle-joint." 

In  the  same  work  the  author  remarks,  at  page  144 :  "  The 
majority  of  writers  have  too  little  regarded  the  condition  of  the 
ligaments  in  cases  of  clubfoot,  nor  has  any  allusion  been  made  to 
the  subject  in  some  of  the  principal  works  on  Orthopaedic  surgery. 
In  Dr.  Little's  work  we  have  no  description  of  any  structural 
alterations  in  the  ligaments  either  in  infantile  or  adult  cases  of 
club-foot."  *  *  *  "  The  ligaments  gradually  adapt  themselves 
in  length  and  form  to  the  altered  form  and  position  of  the  bones 
they  naturally  serve  to  connect,  in  proportion  to  the  time  the 
deformity  has  existed  previous  to  birth,  and  also  in  proportion  to 
the  severity  of  the  muscular  contraction  which  determines  the 
exterior  form  of  the  foot." 

By  this  very  eminent  authority,  it  is  admitted  that  the  ligaments 
are  subject  to  structural  impairment,  attributable  to  unfavorable 
muscular  influence  tending  to  this  abnormal  condition  of  the  liga- 
ments. Is  it  not  reasonable  to  believe  that  this  structural  lesion  of 
ligaments  may  be  the  primary  cause  of  muscular  shortening  in  some 
cases,  and  muscular  shortening  in  that  of  others,  impairing  the 
Integrity  of  the  ligaments?  The  ligaments  certainly  do  yield  to 
continued  elastic  force  other  than  that  of  muscular  contraction  ;  as 
in  the  case  of  acquired  deformity  of  the  foot  from  continued  mal- 
position in  the  favoring  of  a  sensitive  part,  or  unfavorable  position 
from  whatever  cause ;  for  instance,  the  continued  resting  upon  a 
limb  in  playing  the  harp,  which  is  known  to  result  in  contortion 
of  the  body.  The  unfavorable  position  may  be  sustained  by  the 
muscles;  but  the  primary  fixed  condition  is  attained  by  ligamental 
adaptation  —  some  shortened  and  others  elongated  —  and  in  extra- 
ordinary congenital  cases  these  ligaments  are  rigidly  fixed  with  that 
of  an  abnormal  adaptation  of  the  bones  to  the  incurvature  of  the  foot 


50 


ORTHOPuEDIA. 


THE  CONDITION  OF  THE  MUSCLES  IN  TALIPES  VARUS. 

The  muscles  in  congenital  talipes  varus,  at  an  early  period  after 
the  birth  of  the  child,  are  nsnally  of  normal  size ;  the  legs  fully 
developed,  and  the  feet  apparently,  but  slightly,  varied  from  normal 
form,  the  inner  margin  of  the  feet  having  a  vertical  tendency.  For 
a  few  weeks  after  birth,  also,  the  contorted  foot  can  be  restored  to 
the  desired  form  by  the  hand,  and  without  apparent  pain  to  the 
child,  that  is,  in  ordinary  cases;  and  if  sustained  with  appliances, 
a  cure  is  effected  simultaneously  with  the  growth  of  the  child. 

In  this  condition  of  the  foot,  the  gastrocnemius  soleus  and 
plantaris  may  be  considered  as  alone  concerned  in  the  production 
of  the  deformity;  when,  after  a  year  has  elapsed  (the  child  walking), 
the  tibiales  posticus  and  anticus  will  be  found  tense  and  somewhat 
unyielding;  also^  that  of  the  ligaments  on  the  inner  side  of  the 
foot  and  plantar  aponeurosis;  the  tendency  increasing  with  its  age 
and  physical  strength. 

The  relative  position  of  the  tendon  tibialis  posticus,  in  severe 
cases,  is  to  be  found  rather  on  the  internal  malleolus  than  behind,  in 
its  normal  position,  and  is  the  result  of  the  obliquity  of  the  os  calcis. 

Figure  24.  A 
Posticus  tibial  ten- 
dons ;  B,  Plantar 
aponeurosis;  C, 
Tendo-Achillis. 

Figure  25  repre- 
sents the  anterior 
tendons.  A,  An- 
terior tibial  t  e  n  - 
don ;  B,  Peronseus 
tertius  ;  C,  The  os 
calcis,  from  its  oblique  position,  is  seen  to  be  pressing  the  external 
malleolus,  and  thus  gives  convexity  to  the  dorsum  of  the  foot. 

The  three  first-named  muscles  are  the  most  implicated  in  talipes 
varus,  the  anterior  tibial  tendon  and  plantar  aponeurosis  being  only 
implicated  in  severe  cases,  as  represented  in  figures  17  and  18. 


Fh).  24. 


Fig.  25. 


IMPAIR3IENT  OF  TISSUES  RESULTING  IN  CONTORTIONS.      51 


Pig.  26. 


INFLUEKCB    OF   LIGAMENTS   IK   TALIPES   VAEUS. 

If  congenital  varus  remains  unrelieved  during  the  growth  of  the 
foot,  the  ligaments  present  one  of  the  most  formidable  obstacles  to 
the  restoration  of  the  foot  to  its  normal  condition ;  and  even  in 
infants,  when  much  deformity  exists,  tend  to  retard  a  speedy  cure. 
This  influence  is  determined  by  the  rigidity  of  the  foot ;  hence,  a 
tolerably  c-ertain  diagnosis  may  be  obtained  by  grasping  the  foot 
and  making  an  attempt  to  redress  the  deformity,  when,  if  the  liga- 
ments are  not  very  tense,  the  foot  will  assume  an  almost  normal 
form.  At  the  same  time,  however,  care  must  be  taken  to  observe 
the  resistance  of  the  child.  The  best  time  to  examine  the  foot  is 
when  the  child  is  asleep. 

In  non-congenital  cases  of  contortion  of  the  feet,  which  arise 
from  infantile  paralysis  or  unfavorable  influence  from  various 
causes,  this  tendency  to  rigidity  of  the  ligaments 
is  not  so  prevalent  a  concomitant  as  in  that  of 
congenital  contortion,  being  much  more  readily 
restored  to  normal  form. 

Figure  26  represents  the  first  appearance  of 
talipes  varus  from  unfavorable  position,  or  the 
result  of  partial  paralysis. 

Figure  27  is  the  representation  of  the  result  of 
compression,  moulding  the  foot  into  permanent 
deformity,  as  in  the  foot  of  the  Chinese  lady,  as 
represented  in  Mr.  W.  Adams'  work  on  club-foot. 
The  plantar  fascia,  in  some  cases,  tends 
greatly  to  maintain  the  deformity,  and  is  often 
a  serious  obstacle  in  the  treatment  of  contorted 
feet  of  adults  from  its  shortened  condition  ;  in 
all  cases,  therefore,  it  should  be  carefully  exam- 
ined. In  some  it  is  only  a  tense  band,  and  in 
others  a  body  of  considerable  breadth.  When 
divided,  the  foot  slowly  extends,  all  other  parts 
being  disposed  to  yield. 

The  legs  of  persons  who  have  had  contorted 
feet  for  a  considerable  period  are  generally 
remarkably  attenuated,  the  cause  being  vari- 
ously accounted  for,  but  it  is  usually  attributed  to  the  quiescence 
of  the  muscles,  resulting  in  firm  contraction  and  consequent  rigidity. 


52  Orthop^dia. 

impeding  the  circulation  essential  to  nutrition,  the  structure  of  the 
muscles  having  long  remained  in  an  abnormal  condition.  This 
occurs  chiefly  in  confirmed  congenital  club-foot.  The  facing  of  the 
muscles  by  sub-cutaneous  section  tends  to  their  improvement  in 
development,  but  not  to  the  extent  of  the  normally-conditioned 
limb,  nor  to  equal  strength,  yet  they  apparently  recover  their  origi- 
nal strength,  the  patient  frequently  being  able  to  walk  for  short 
distances  without  impediment  or  difficulty. 


CONTORTIOIT   RESULTING   FROM   PARALYSIS. 

In  non-congenital  cases  of  talipes  some  of  the  muscles  become 
shortened,  because  of  their  tendency  to  recover  from  impairment 
in  tone,  while  others  remain  flaccid;  first,  from  the  paralytic 
influence ;  and,  sec07idly,  from  fixed  extension.  If  not  relieved 
fatty  degeneration  ensues  at  an  early  period,  and  continues  until 
an  equilibrium  of  action  is  established  in  all  the  muscles  of  the 
limb  —  a  favorable  result  obtains  from  treatment  in  nearly  all  cases 
of  infantile  paralysis,  and  occasionally  in  children  up  to  the  age  of 
sixteen.  The  sarcolemma  of  the  muscular  tissue  maintains  its 
integrity,  and  under  a  favorable  condition  reinstates  muscular 
fibre  to  nearly  the  full  development  of  the  normal  muscle. 

Years  of  perseverance  in  treatment  may  be  required  in  extraor- 
dinary cases,  but  when  properly  constructed  apparatus  is  applied 
and  kept  in  repair,  and  physiological  treatment  judiciously  pre- 
scribed and  enforced,  the  restoration  of  power  is  most  certain. 


SURGICAL    TREATMENT   OF    CONTORTED   FEET. 

The  treatment  of  contortion  of  the  body  and  limbs  requires 
special  practical  knowledge  more  than  any  other  of  the  ordinary 
branches  of  surgical  science.  The  mechanical  and  scientific  ac- 
quirements necessary  to  insure  successful  practice  consist  in  the 
ability  to  devise  the  therapeutical  means  for  treatment  that  will  be 
applicable  to  the  apparent  indications  that  present  themselves,  or 
may  arise  in  the  course  of  treatment.  And  it  is  quite  true  that 
this  attainment  of  practical  ability  to  construct  surgical  apparatus 


Iatpairment  of  Tissues  Resulting  in  Contortions.     53 

is  within  the  province  of  the  general  practitioner.  A  scientific, 
skilful  surgeon  never  hesitates  to  prescribe  the  apparatus  required 
for  an  extraordinary  fracture  or  lesion  of  the  body  or  limbs  when 
something  of  peculiar  form  is  demanded.  So  in  the  treatment  of 
contortions,  an  essential  qualification  is  the  ability  not  only  to 
prescribe  the  necessary  apparatus,  but  to  devise  such  modifications 
as  the  various  conditions  may  suggest ;  and  we  cannot  conceive  of 
any  actual  division  of  mechanical  and  surgical  treatment  for  the 
cure  of  contortion  of  feet,  limbs  or  body.  If  the  subsequent 
ti'eatment  or  devising  of  apparatus  is  submitted  to  the  skill  of  the 
mechanic,  it  is  a  procedure,  strongly  indicative  of  a  want  of  practical 
experience  on  the  part  of  the  surgeon. 


PEEPAEATORY   STEPS   IIST   TEEATMENT. 

The  primary  steps  in  the  treatment  of  contortion  of  the  feet  are 
necessarily  the  severing  of  tendons,  commencing  with  that  of  the 
tendo-Achillis  and  its  accompanying  tendons  conjoined  and 
attached  to  the  distal  portion  of  the  os  calcis. 

Before  commencing  the  operation,  the  dressings  should  be  in 
readiness,  consisting  of  soft  cotton  fabric  firmly  rolled  and  of  the 
following  dimensions  for  each  foot ;  For  an  adult,  one  of  two  and  a 
half  inches  wide  and  two  and  a  half  yards  long,  with  another  of 
a  yard  in  length.  Eor  infants,  dressings  of  half  the  size  and 
length.  The  additional  requisites  are :  A  strip  of  court  plaster,  a 
small  pledget  of  soft  woven  fabric  folded  three  or  four  layers  thick, 
about  two  inches  square,  and  wet  with  water;  a  sufficient  quantity 
of  lint  to  protect  the  points  of  pressure  from  the  shoe,  being  at 
the  inner  side  of  the  heel,  the  cuboid  bone,  and  the  outer  edge  of 
the  anterior  portion  of  the  foot,  and  on  the  instep ;  the  shoe  to  be 
applied,  and  a  sponge  and  basin  of  water. 

The  patient  is  now  placed  on  a  table  or  bed,  face  downward,  and 
with  the  feet  projecting  over  the  edge.  Care  must  be  taken  to 
have  the  patient  properly  held  by  assistants,  and  especially  the 
limb  to  be  operated  on.  If  an  adult,  have  an  assistant  to  maintain 
the  foot  firmly  in  position,  and  keep  the  tendon  extended  mode- 
rately, being  attentive  to  direction,  and  relaxing  the  tension  at  the 
instant  the  knife  has  severed  the  tendon. 


54  Ortrof^bia. 

means  of  eestoriifg  the  eoot  to  normal  form. 

The  patient  properly  prepared  for  the  operation,  we  carefully 
examine  the  tendon  to  determine  its  size  and  relative  position,  and 
depth  beneath  the  external  integument;  then  insert  the  knife,  flat 
surface  under  the  tendon,  about  one  inch  above  the  os  calcis  —  pas- 
sing it  first  obliquely  downward  and  close  to  the  tendon  —  and  then 
depress  tlie  handle,  to  avoid  penetrating  too  deeply,  when  under. 
The  tendon  now  being  fairly  upon  the  blade  of  the  knife,  turn  the 
cutting  edge  to  the  tendon,  pressing  the  knife  firmly,  and,  with  a 
short  sawing  movement,  sever  the  tendon  slowly  and  carefully  —  to 
the  protection  of  the  other  tissues  —  then  turn  the  knife  flatwise 
and  withdraw  it  with  care,  so  as  to  avoid  enlarging  the  aperture, 
which  must  be  closed  instantly  and  covered  with  the  court  plaster. 
The  folded  pledget,  being  moistened,  is  then  applied  over  the  court 
plaster  and  secured  by  a  few  turns  of  the  roller.  The  dry  lint  is 
next  applied  and  secured  by  the  roller,  and  when  this  is  completed, 
the  foot  placed  carefully  in  the  shoe,  and  lightly  secured  by  placing 
on  the  instep  the  pad,  having  tapes  attached,  which  pass  through 
an  opening  in  the  heel  of  the  shoe,  and  are  returned  and  tied  on 
the  instep  pad.  The  anterior  of  the  foot  is  then  secured  with  the 
short  roller,  as  will  be  described  in  another  chapter.  After  the 
operation  the  nurse  is  directed  to  have  the  leg  carefully  supported 
upon  a  pillow  or  other  soft  material,  and  kept  in  a  horizontal  posi- 
tion, sitting  or  lying,  as  may  be  most  agreeable  to  the  patient,  who 
is  kept  for  two  weeks  confined  to  his  room  and  precluded  from 
walking  or  standing,  and  during  that  period,  after  which  time  he  is 
permitted  to  gently  press  the  foot  upon  the  floor,  using  as  a  support 
the  back  of  a  chair  which,  when  inclmed  to  walk,  he  can  push 
before  him.  This  is  continued  for  two  weeks  more,  when  he  may 
be  permitted  to  walk  independent  of  support. 

When  the  sequence  of  paralytic  seizures  are  presented  for  treat- 
ment—  the  leg  greatly  attenuated  and  the  foot  distorted  by  a  short- 
ening of  the  tendo-Achillis — after  severing  the  tendon  in  such 
cases,  the  foot  should  be  extended  and  secured  by  a  straight  splint 
for  ten  days.  This  will  insure  the  union  of  the  tendon,  though  it 
will,  for  a  comparatively  limited  time,  retard  the  restoration  of  the 
foot  to  proper  form.  One  of  the  most  unfortunate  conditions 
in  which  a  patient  can  be  placed  is  to  have  the  tendo-Achillis  un- 
united.    His  condition  is  pitiable  indeed;  compelled  as  he  is  to 


1MPAIR3IENT  OF  TISSUES  RESULTING  IN  CONTORTIONS.      55 

wear  a  heavy  and  expensive  apparatus  for  the  remainder  of  life, 
and  even  this  giving  only  tolerable  facility  in  locomotion.  How 
damaging  to  the  reputation  of  the  surgeon  are  such  sad  catastro- 
phes, occurring  as  they  have,  simply  from  a  lack  of  attention. 

We  have  never  seen  arteries  punctured  tending  to  any  serious 
result ;  while  Mr.  Adams  and  others  inform  us  it  has  unfortunately 
occurred;  but  ordinarily  with  little  injury  to  the  patient,  hemor- 
rhage having  been  arrested  by  pressure. 

Suppuration  of  the  tendon  sometimes  ensues,  and  this  we  have 
specially  observed  in  patients  of  strumous  diathesis,  but  never  to 
the  extent  of  arrest  of  the  recuperative  process.  The  period  of  rest 
enjoined  was  protracted,  but  the  patient's  condition  readily  improved 
by  alterative  tonics  and  liberal  diet. 


SEVERIlSrG   THE   PLAISTTAR   FASCIA. 

In  cases  where  there  is  much  shortening  of  the  plantar  fascia, 
together  with  shortening  of  the  tendo-Achillis,  we  divide  bom  at 
the  same  time.  We  have  had  cases,  however,  that  required  only, 
for  the  perfect  restoration  of  the  foot,  the  severing  of  the  plantar 
fascia.  The  patient  being  placed  in  a  favorable  position,  and 
properly  supported,  in  the  case  of  an  adult,  the  plantar  surface  of 
the  foot  is  supported  and  extended  by  an  assistant  —  we  carefully 
examine  the  tense  mass  of  tissue,  defining  its  breadth  as  nearly  as 
possible.  We  now  insert  the  tenotome  (the  same  size  used  in  the 
severing  of  the  tendo-Achillis)  about  midway  of  the  length  of  the 
fascia  and  close  on  the  inner  border  pass  to  the  supposed  extent  of 
contraction,  closely  engaging  the  mass  to  be  divided  ;  then  turn  the 
cutting  edge  to  the  fascia  and  gently  maneuvre  to  the  completion 
of  the  operation.  The  foot  will  elongate,  but  not  to  the  extent 
that  might  be  reasonably  expected  from  the  severing  of  a  fascia,  to 
all  appearances  strongly  contracted.  The  longitudinal  arch  of  the 
foot  yields  slowly  even  to  a  very  firm  pressure  upon  the  instep, 
the  bearings  of  the  plantar  surface  being  supported  upon  a  metal 
plate,  which  afi'ords  the  facility  for  making  that  pressure  by  means 
of  the  roller. 

The  section  of  the  fascia  being  completed,  care  must  be  taken  to 
close  the  wound,  apply  the  court  plaster  and  moistened  pledget,  and 


56  Or  thopjebia. 

then  tlie  roller,  with  lint  to  protect  the  points  of  bearing  upon  the 
foot  and  guard  against  any  injurious  pressure.  The  shoe  is  next 
applied  with  some  firmness,  and  if  the  tendo-Achillis  has  not  been 
severed,  the  patient  is  allowed  to  bear  weight  upon  the  foot  imme- 
diately, if  so  disposed ;  in  fact,  encouraged  to  do  so. 

We  have  never  witnessed  any  injury  proceeding  from  the  division 
of  this  fascia,  although  well  authenticated  cases  exist  where  an 
artery  has  been  punctured  and  followed  by  most  serious  results. 
Mr.  E.  M.  Tamplin  informs  us  that  he  assisted  in  an  operation 
where  an  artery  was  punctured,  and  that  after  the  lapse  of  several 
weeks,  a  most  difficult  operation  was  necessitated  and  performed  to 
arrest  the  bleeding  of  the  wounded  artery,  well  devised  compression 
having  been  of  no  avail.  Hence,  the  necessity  for  extreme  care  in 
performing  this  operation  upon  the  plantar  fascia,  more  especially 
in  the  case  of  very  young  subjects. 

These  are  the  only  surgical  conditions  requiring  tenotomy  in  the 
first  and  second  stages  of  talipes  varus.  By  the  careful  application 
of  means  for  extension  with  that  of  manipulation,  the  latter  being 
a  very  essential  adjuvant  to  the  treatment,  a  cure  may  be  obtained 
in  nearly  every  case.  In  congenital  cases,  where  the  foot  can  be 
straightened  with  the  hand,  we  apply  a  modified  Scarpa  shoe 
(described  in  another  chapter)  at  the  age  of  six  weeks.  If,  during 
the  following  five  or  six  weeks  of  persistent  efibrt,  the  perfect 
adjustment  of  the  shoe  be  found  impossible,  the  parents  of  the 
child  are  advised  to  suspend  further  treatment  until  it  is  six  months 
old,  when  we  sever  the  tendons  and  give  special  attention  to  the 
redressing  of  the  deformity.  That  many  cases  of  congenital  club- 
foot can  be  cured  by  perseverance  in  well-directed  manipulation,  a 
doubt  cannot  be  entertained.  The  failure  may  be  attributed  to  the 
inattention  of  mothers  and  nurses  who  become  discouraged  from 
the  slow  progress  made  in  these  first  efforts  ;  and  the  great  difficulty 
attending  the  securing  the  foot  in  a  retaining  shoe,  and  more  often 
from  indiscretion  in  bandaging  the  foot  too  tight  for  that  purpose ; 
and  the  result  produced  excoriations,  subjecting  the  child  to  much 
suffering  and  delay  in  the  progress  of  extension.  Hence,  many 
cases  are  treated  by  the  preparatory  step  of  tenotomy,  which 
renders  the  foot  less  resistant  to  subsequent  treatment. 


Impairment  of  Tissues  Resulting  in  Contortions.     57 


THIKD    STAGE    OF   TALIPES   VARUS. 

In  the  third  stage  of  talipes  varus,  cases  present  a  more  compli- 
cated character ;  the  foot,  being  decidedly  more  folded  upon  itself, 
does  not  yield  readily  to  force.  The  tissues  that  tend  to  sustain 
this  abnormal  form  are  additional  to  those  described  as  requiring 
tenotomy  in  the  first  and  second  stages.  ISToav  we  have  the  posterior 
tibial,  flexor  longus  digitorum  and  anterior  tibial  tendons  to  elon- 
gate. Many  surgeons  advise  the  severing  of  all  the  apparently  tense 
tendons  at  one  time  in  cases  of  only  ordinary  tenseness,  which, 
they  state,  facilitates  subsequent  treatment.  We,  however,  of  late 
years  seldom  sever  the  three  last-stated  tendons,  and  are  quite  as 
successful  in  redressing  the  contorted  foot  as  when  we  divided  them, 
the  rigidity  of  the  foot  being  dependent  upon  the  ligaments,  and 
these  cannot  all  be  reached  by  the  knife. 

In  the  treatment  of  talipes  (the  generic  term  given  by  Menzel  *), 
like  that  of  practice  in  other  practical  procedures  in  surgery,  intel- 
ligent, experienced  practitioners  do  not  confine  themselves  to  any 
precedent  that  may  be  varied  without  adventure,  to  the  imperilling 
the  life  of  their  patient,  or  that  it  is  seemingly  possible  to  make 
an  improvement  upon,  in  relieving  the  suffering  from  unnecessary 
pain,  and  facilitate  cure  by  a  more  perfect  coaptation  of  surgico- 
mechanical  apparatus.  Each,  of  course,  will  devise  various  means 
of  arriving  at  the  one  desired  object,  the  most  speedy  and  perfect 
cure  of  the  patient.  Hence,  it  is  well  for  the  young  aspirant  in 
surgery  to  examine  carefully  the  practice  and  ingenious  devices  of 
those  most  noted  for  their  skill,  determining  which  course  he  will 
pursue,  and  then  make  it  available  by  his  own  ingenuity,  even  to 
bhat  of  an  entire  change  in  treatment  and  reconstruction  in  the 
appliances. 


ON"   SEVEEING   THE    POSTERIOR   TIBIAL   TENDON". 

The  sub-cutaneous  section  of  the  posterior  tibial  tendon,  and  that 
of  the  flexor  longus  digitorum  are  often  included  in  the  one  opera- 
tion, which  we  defer  to  a  subsequent  period.     Our  reasons  for  so 

*  "  Dissertatio  Indergeralis  medica  Talipedibus  varis  auctore."—  D.  M.  Men- 
zel, Terbing,  1798. 


58  Or  thop^dia  . 

doing  are,  that  by  dividing  the  tendo-Achillis  and  plantar  fascia, 
the  tense  resistance  is  relieved  to  a  considerable  degree,  and  the 
contortion  overcome  by  careful  manipulation,  together  with  suit- 
able apparatus.  We  avoid  any  risk  of  wounding  arteries  from  the 
severing  of  the  posterior  tibial  tendon  above  the  internal  malleolus, 
inasmuch  as  a  space  presents,  by  this  procedure,  between  the  inter- 
nal malleolus  and  the  os  naviculare,  where  the  tendon  may  be 
severed  with  comparative  safety,  and  without  danger  of  wounding 
the  artery  or  nerves.  Again,  if  the  tendo-Achillis  and  plantar 
fascia  are  not  first  divided  and  the  foot  everted  by  means  of  exten- 
sion apparatus,  it  is  impossible  to  sever  the  posterior  tibial  tendon 
at  the  point  we  have  just  described. 

Mies,  of  Hanover,  states  that  the  scaphoid  bone  is  displaced  and 
firmly  held  in  contact  with  the  inner  malleolus  by  the  contraction 
of  the  posterior  tibial  muscle,  the  tendon  of  which,  therefore,  does 
not  pass  below  and  in  front  of  tlie  inner  malleolus,  as  in  the  nor- 
mally-conditioned limb. 

Mr.  William  Adams  says  that :  "  In  slight  congenital,  and  in 
most  of  the  non-congenital  cases,  this  operation  may  be  performed 
in  the  situation  recommended  by  Mr.  Syme  (that  of  severing  the 
tendon  in  front  of  the  inner  malleolus),  but  in  such  cases  its  divis- 
ion is  seldom  required." 

It  is  very  true  that  this  operation  is  but  seldom  required  for  talipes 
varus,  or  that  of  the  antei'ior  tibial,  which  is  readily  severed  near 
to  its  insertion  where  it  crosses  the  ankle  joint,  as  it  is  there  quite 
prominent,  except  in  very  fleshy  infants,  and  even  then  can  be 
detected  by  bearing  in  mind  that  it  is  inclined  to  the  inner  side  of 
the  foot,  from  having  become  shortened,  and,  when  detected,  the 
finger  should  be  kept  upon  the  tendon,  and  the  knife  so  inserted 
and  guided  as  to  have  the  point  pass  beneath  or  over  the  tendon 
flahoise  ;  then  turned,  and  the  tendon  severed. 

By  the  sub-cutaneous  section  of  the  tendo-Achillis  (or  other  ten- 
dons when  necessary),  the  patient  is  not  only  more  readily  cured  of 
contorted  feet,  but  is  relieved  from  a  vast  amount  of  suffering,  both 
physical  and  mental,  incident  upon  treatment  for  contortion  without 
severing  the  tendons. 

Continued  extension,  in  attempts  at  the  accomplishment  of  so 
desirable  an  object,  subjects  the  patient  to  great  pain  continued 
through  years;  and  is  often  attended  with  results  unfavorable  to  the 
patient's  health. 


Impairment  of  Tissues  Resulting  in  Contortions.    59 

tkeatment  of  punctured  arteries. 

We  do  not  hesitate  to  sever  tendons  sub-cutaneously  when  persist- 
ent in  maintaining  a  contortion,  and  in  a  measure  free  from  com- 
plication with  important  blood-vessels  and  nerves.  Arteries  in  the 
feet  have  been  wounded,  as  that  of  the  posterior  tibial,  and  relieved 
by  styptics  and  pressure.  Mr.  William  Adams  relates  the  case  of 
an  exceedingly  interesting  cure  that  occurred  in  his  own  practice : 
"On  April  13,  1853,  I  wounded  the  posterior  tibial  artery  in  a  child 
seven  weeks  old.  The  blunt-pointed  knife  was  used,  and  I  was  not 
aware  of  the  accident  at  the  time  of  the  operation.  As  neither  tlie 
arterial  jet  nor  the  sudden  blanching  of  the  foot  indicated  the  mis- 
chief, the  artery  was  probably  only  wounded." 

"  After  the  lapse  of  ten  days  a  deep  pulsating  tumor  was  discov- 
ered ;  and  direct  pressure  by  a  graduated  compress  and  bandage  was 
applied.  The  pulsation  diminished,  but  a  very  small  slough  formed 
in  consequence  of  the  pressure  not  being  relieved  for  four  days,  from 
neglect  of  the  mother  to  attend  at  the  hospital,  and  a  copious 
arterial  hemorrhage  took  place.  Pressure  a  little  above  the  aneurism 
appeared  to  command  the  bleeding,  and  was  therefore  tried,  but 
discontinued  on  the  second  day  from  the  extension  of  the  swelling 
to  this  part  of  the  leg." 

"  This  pressure  having  been  removed,  a  second  arterial  bleeding 
followed.  On  May  12,  1853,  I  injected  from  five  to  ten  drops  of  the 
concentrated  solution  of  perchloride  of  iron,  as  recommended  by 
M.  Pravaz,  of  Lyons,  into  the  centre  of  the  aneurism,  which  .was 
probably  an  inch  in  diameter.  At  the  time  of  the  injection  clotted 
blood  plugged  the  small  cutaneous  ulcer,  through  which  the 
extremity  of  a  long  and  finely  pointed  glass  syringe,  containing  the 
styptic,  was  introduced  and  carried  to  some  depth." 

"  Both  before  the  injection  and  for  five  minutes  afterward,  M. 
Lonsdale  compressed  the  femoral  artery,  so  as  to  insure  the  blood 
acted  upon  being,  as  nearly  as  possible,  in  a  stagnant  condition  —  a 
most  essential  point.  The  first  effect  observed  was  that  the  loosely- 
clotted  blood,  filling  the  cutaneous  ulcer,  became  firmer,  and  that 
from  ten  to  twenty  minims  of  straw-colored  serum  oozed  through 
the  ulcer ;  affording  conclusive  physiological  evidence  of  the  firm 
coagulation  of  the  blood,  which  was  also  indicated  by  a  general  feel- 
ing of  hardness  over  the  sac.  A  piece  of  lint  and  a  light  bandage 
was  applied." 


60  Ortrop^dia. 

"  The  cataueous  ulcer  showed  itself  the  next  day  to  be  contracted, 
and  plugged  with  a  firm,  black  clot.  The  surrounding  skin,  which 
previous  to  the  operation  had  presented  a  tense,  shiny,  swollen  and 
slightly  reddened  appearance,  was  now  pale  and  less  tumefied.  The 
aspect  of  the  limb  was  remarkably  changed,  and  a  process  of  shrink- 
ing and  contraction  appeared  to  have  commenced,  so  that  no  inflam- 
matory results  were  apprehended.  Progressive  improvement  took 
place;  the  ulcer  healed  in  a  week  and  the  shrinking  and  contracting 
advanced.  On  May  25th  a  deep  puckered  cicatrix,  and  a  little 
deeper  seated  induration  alone  indicated  the  former  seat  of  the 
aneurism." 

We  have  given  the  particulars  of  the  case  as  practical  information, 
to  enable  the  surgeon  who  may  be  so  unfortunate  as  to  require  more 
than  the  ordinary  means  of  arresting  the  hemorrhage,  resulting 
from  an  accidental  puncture  of  an  artery ;  or,  as  in  the  case  of  Mr. 
Adams,  having  punctured  the  artery,  meet  with  the  subsequent 
aneurism  resulting  in  hemorrhage.  We  have  accidentally  wounded 
the  posterior  tibial  artery,  but  never  failed  in  arresting  the  hemor- 
rhage by  graduated  compression,  carefully  applied  for  about  twelve 
hours ;  then  relieved  and  only  moderately  supported  by  compress 
and  roller.  Special  care  must  be  practiced  in  the  arresting  of  hem- 
orrhage, from  an  artery  thus  woundei,  by  applying  a  small  compost 
compress  as  soon  as  possible,  even  to  a  small  jetting  stream,  when 
moderate  pressure  will  arrest  the  bleeding.  If  permitted  to  flow  for 
any  duration  of  time,  the  difficulty  of  arresting  it  will  be  in  pro- 
portion ;  and,  if  secured  from  flowing  externally  will  become  infil- 
trated from  the  increased  impetus,  and  finally  form,  as  in  Mr. 
Adams'  case,  a  pulsating  tumor. 


TENOTOMY     KNIVES. 


Orthopaedists  differ  considerably  in  regard  to  the  form  of  the 
knives  to  be  used  in  their  practice ;  some  having  blades  of  various 
shapes,  while  others  are  satisfied  with  one  or  two  forms,  with  which 
they  perform  all  the  operations  pertaining  to  orthopajdic  surgery  — 
all  agreeing,  however,  that  the  blade  must  be  of  such  a  form  and 
size  as  will  make  the  smallest  possible  aperture  in  the  external 
integument ;  and  hence  they  have  rounded  shanks  and  short  cut- 


Impairment  of  Tissues  Eesulting  in  Contortions.     61 


Fig.  38. 


ting  edges;  some  straight  and  spear  pointed,  some  curved,  and  others 

of  a  blunt  pattern.     See  Fig.  28. 

The  No.  1  is  suitable  for  operat- 
ing on  infants,  and  on  tendons  on 
the  anterior  aspect  of  the  feet  of 
adults. 

No.  2,  for  severing  the  tendo- 
Achillis  in  adults  in  ordinary  cases. 
No.  3,  for  severing  tendons  or 
muscles  where  special  care  is  re- 
quired to  avoid  wounding  an  artery 
or  nerve,  incision  being  made 
through  the  integument  to  the 
tendon  or  muscle,  then  the  blunt 
knife  inserted  so  as  to  engage  only 
that  which  is  to  be  divided. 
No.  4  is  simply  a  large  sized  tenotome  —  at  times  required  for 
severing  a  muscle  or  broad  fascia.  The  forms  of  tenotomes  claim 
some  consideration.  The  smallest  knife  in  use  is  three-fourths  of 
an  inch  in  length  of  cutting  convex  edge  ;  the  back  nearly  straight, 
having  a  cutting  edge  of  about  one-eighth  of  an  inch,  tending  to  a 
point,  the  remainder  of  the  back  being  obtusely  angular.  The 
breadth  of  the  blade  is  full  three-sixteenths  of  an  inch  in  the  mid- 
dle. The  knife  should  be  thick  enough  to  ensure  good  strength, 
and  increased  in  size  for  special  purposes,  as  that  of  dividing  broad 
fascise,  muscles,  and  tendons  of  adults.  The  shanks  should  be 
rounded,  and  of  about  three-fourths  of  an  inch  to  the  blade  of  the 
tenotome.  The  handles  are  from  three  to  four  inches  in  length, 
flat  or  octagonal,  as  may  be  desired. 


No.  1. 


No.  2. 


CHAPTER  in. 

GENERAL  REMARKS  OX  T3E  TREATMENT  OF  TALIPES. 

Mr.  William  Adams"  treatment. —  His  modification  of  Scarpa's  shoe. —  Illus- 
tratire  cases. —  Detailed  description  of  modern  treatment. —  Transverse  tarsal 
joint  a  chief  xjoiut  to  be  considered  in  treatment. —  India-rubber  cords  unre- 
liable.—  Mea^ts  of  cruE  ix  first  stage  of  talipes  varus. —  The  author's 
modification  of  Scarpa's  shoe. —  Treatment  of  adults  in  talipes  varus. —  Extra- 
ordinary case  of  cure. —  The  modified  Scarpa  shoe  applicable  to  nearly  all  vari- 
eties of  club-foot. —  Secoxd  stage  of  talipes  varus,  axd  treatment. — 
Prognosis  as  to  cure. —  Treatment  in  cases  of  excoriation. —  Fallacy  of  Prof. 
Syme's  statements. —  Third  stage  of  talipes  varus. —  Description  of  condi- 
tion of  patient. —  Mode  of  treatment. —  Treatment  occasionally  deferred. — 
Causes  of  valgus,  and  condition  of  the  bones. — Treatment  of  talipes  valgus. — 
The  tendo-Achillis  must  be  severed  in  severe  cases. —  Talipes  equino-varus 
the  result  of  unskilful  treatment. —  Description  of  apparatus  for  first  stage 
of  talipes  valgus — Treatment  of  extreme  cases. —  Extension  apparatus. — 
Method  of  application  of  the  modified  Scarpa  shoe. —  Treatment  of  extreme 
cases  of  talipes  valgus. —  First  stage  of  treatment. —  Second  stage  of  treat- 
ment.—  Faradization  of  much  service,  when  applied  to  the  paralyzed  mus- 
cles.—  Talipes  equixus. —  Distinguishing  features  in  this  ailment. —  Author- 
ities differ  as  to  origin. —  Congenital  talipes  equinus  extremely  rare. —  Con- 
traction OF  THE  PLANTAR  APONEUROSIS. —  Objectionable  points  in  Scarpa's 
shoe. —  Professor  Mutter's  shoe. —  Causes  of  talipes  equinus. —  Most  frequently 
the  result  of  paralysis,  induced  during  dentition. —  Other  causes. —  Prognosis 
as  to  cure. —  Treatment. —  Action  of  the  apparatus. —  Talipes  equinus  from 
spastic  influence. — Talipes  calcaneus. — Diagnosis. — The  Hospital  for  the 
Relief  of  the  Ruptured  and  Crippled,  a  priceless  boon  to  the  suffering  poor. — 
Cause  of  congenital  talipes  calcaneus  a  disputed  point. — Seldom,  if  ever,  met 
with  in  tlie  adult. — Treatment  of  congenital  talipes  calcaneus. — Severance  of 
tendons  exceptional. — Treatment  of  non-congenital  talipes  calcaneus. — Tenot- 
omv  seldom  required  in  its  incipient  stages. — Description  of  extension  appa- 
ratus. 


Before  describing  our  treatment  of  the  several  varieties  of  talipes, 
a  brief  quotation  from  the  writings  of  one  of  the  most  eminent 
orthopedic  practitioners  in  London,  in  relation  to  the  primary  treat- 
ment, subject,  however,  to  modification,  may  not  be  amiss. 

Mr.  William  Adams,  in  his  work  published  in  London  in  1866, 
page  106,  says :  ''When  any  lateral  inclination  of  the  foot  exists, 
usually  inversion,  or  an  inclination  to  varus.  I  make  use  of  a  cog- 


General  Remarks  on  the  Treatment  of  Talipes.    63 


Fig.  39. 


wheel  placed  in  the  sole  of  the  Scarpa  shoe,  which  is  divided  trans- 
versely, as  repi'esented  in  figure  14 ;  the  mechanical  centre  of  motion 
is  thus  made  to  correspond  to  the  transverse  tarsal  joint  in  the  foot, 
w^hich  is  the  anatomical  centre  of  motion  in  this  portion  of  the 
deformity. 

"  It  is  an  error  to  attempt  to  overcome  the  inversion  or  eversion 
of  the  foot  (or  rather  of  its  anterior  portion  in  front  of  the  trans- 
verse tarsal  joint,  which  can  only  be  involved  in  any  such  move- 
ment,) by  a  cog-wheel  acting  laterally,  and  placed  opposite  the 
ankle-joint,  as  in  the  ordinary  Scarpa  shoe.  *  *  *  For  the  sake 
of  adjustment  in  very  slight  cases  this  may  be  used;  but  if  any 
decided  degree  of  inversion  or  eversion  has  to  be  overcome,  I  never 
use  the  so-called  double  cog-tvlieel  action  at  the  ankle-joint.  I  pre- 
fer acting  more  directly  upon  the  trans- 
verse tarsal-joint-  by  means  of  the  instru- 
ment represented  in  figure  14." 

Figure  29  represents  Mr.  Adams'  modi- 
fied Scarpa  shoe,  alluded  to  as  figure  14  in 
his  book,  page  106,  which  he  terms  the 
transverse  tarsal  arch. 

Figure  29  :  Scarpa  shoe,  modified  by  Mr. 
Adams,  with  a  transverse  division  in  the 
sole  plate  corresponding  to  the  transverse 
tarsal-joint  in  the  foot,  used  to  control 
inversion  or  eversion  of  the  foot.  In  Mr. 
Adams'  book,  page  118,  it  is  stated  that  the  transverse  division  in 
the  sole  plate  is  moved  by  means  of  a  cog-wheel,  a  means  of  fixed 
force  which  we  consider  objectionable. 

F'"J-  30.  Figure  30.     "  Case  of  Talipes  Equinus  in  a 

boy.  The  deformity  depending  chiefly  upon 
the  foot  being  bent  upon  itself  from  the  trans- 
verse tarsal  joint  indicated  by  the  line  a,  a." 
Mr.  Adams  attaches  much  importance  in 
the  treatment  of  club-foot,  of  whatever  vari- 
ety, to  a  knowledge  of  the  transverse  tarsal 
joint,  and  to  the  modified  Scarpa  shoe  as  in- 
vented by  himself  ;  the  sole-plate  in  this  con- 
sisting of  two  portions  that  admit  of  lateral  movement,  and  con- 
trolled by  a  double  cogwheel  to  the  redressing  of  the  deformity  of 
the  foot. 


64  OrTHOPjEDIA. 

Toward  the  accomplishment  of  the  same  object  (avoiding,  how- 
ever, any  fixed  force  where  an  elastic  one  can  be  applied),  it  will  be 
observed  in  the  subsequent  pages  that  we  apply  the  roller  so  as  to 
invert  or  evert  the  foot  upon  the'  undivided  sole-plate  of  the  Scarpa 
shoe.  This  is  done  by  reversing  the  turns  of  the  roller  —  passing  it 
after  a  few  turns  over  the  foot,  then  in  a  reverse  direction  under 
the  plate,  drawing  the  contorted  foot  upon  the  plate,  or  an  approach 
thereto,  limiting  the  force  to  the  endurance  of  the  patient.  A  few 
turns  are  then  made  over  the  foot  and  plate  to  secure  the  position ; 
the  heel  having  first  been  firmly  fixed  by  means  of  the  instep  pad 
and  tapes.  A  curved  elastic  spring  is  made  to  oppose  the  inward 
tendency  of  the  foot  and  ankle,  having  its  centre  of  force  upon  the 
transverse  tarsal  joint  and  the'  single  elastic  spring  tending  to 
unfold  the  foot,  and  also  to  limit  extension  and  admit  of  flexion  by 
the  limited  joint. 

The  transverse  tarsal  joint  is  to  be  carefully  considered  in  the 
treatment  as  the  axis  of  motion  or  point  of  yielding;  and  that  the 
ankle  joint  is  of  minor  importance,  as  it  sustains  to  a  great  degree 
its  abnormal  relations  from  flexibility,  whilst  the  anterior  of  the 
foot  is  contorted  in  all  the  varieties  of  lateral  deviation  from  abnor- 
mal stress  upon  the  ligament.  That  the  transverse  tarsal  joint 
described  by  Mr.  W.  Adams  is  the  centre  of  motion  may  be  admit- 
ted as  well  as  that  of  rotation  in  varus,  inward  and  upward,  of  the 
anterior  and  posterior  extremities  of  the  foot;  inclining  the  feet 
when  thus  contorted  to  overlap  each  other  in  walking,  from  the 
incurving  of  the  anterior  portioi;  of  the  foot  —  hence  the  primary 
treatment  is  to  unfold  or  extend  the  contorted  foot  which  will,  in 
nearly  every  case,  restore  the  leg  and  foot  to  a  normal  condition. 
And  is  most  successfully  accomplished,  as  the  celebrated  Scarpa 
determined  in  his  day,  by  elastic  force  from  a  steel  spring;  which 
is  a  lateral  force,  whatever  form  the  shoe  may  have.  Much  depends, 
however,  upon  the  practical  skill  of  the  surgeon  in  the  manipula- 
tion of  the  contorted  foot,  and  in  the  utmost  vigilance  to  avoid 
undue  pressure  upon  salient  parts.  Abrasions  of  parts  of  the  foot 
arising  from  this  cause  will  often  retard  progress  in  treatment,  even 
to  the  extent  of  permanent  injury. 

We  consider  India  rubber  cords  unreliable  and  cumbersome  in 
their  application,  and  hence,  have  abandoned  their  use. 

In  the  first  condition  of  talipes  varus  in  children  or  adults,  the 
sole  of  the  foot  rests  upon  the  ground  in  nearly  normal  form ;  the 


General  Remarks  on  the  Treatment  of  Talipes.    65 

outer  margin  presenting  an  increasing  curve,  and  the  plantar  bear- 
ing, limited  to  the  centre  of  the  curve;  the  external  malleolus 
becoming  more  prominent  from  pressure  of  the  proximal  end  of 
the  OS  calcis,  which  is,  at  the  early  stage  of  deformity,  tending  out- 
ward, and  the  anterior  of  the  foot  presenting  little  or  no  change  in 
appearance,  other  than  inclining  inward  and  upward,  as  seen  in 
the  drawings  in  the  previous  tigures. 

This  condition  of  a  tendency  to  an  inward  curving  of  the  feet, 
presents  in  the  new-born  babe,  and  in  all  stages  of  life  even  to  that 
of  old  age  ;  induced  from  various  causes  affecting  the  ligaments, 
muscles  and  tendons.  In  children,  most  frequently,  from  paralysis, 
contusions,  and  ulcerations  of  the  feet ;  in  adults,  from  caries,  indo- 
lent ulcers,  accidental  injuries  of  the  legs,  careless  walking  (on  the 
outer  edge  of  the  feet)  and  continued  from  habit,  and  in  aged  per- 
sons from  a  weakened  condition  of  the  muscles  on  the  anterior 
aspect  of  the  limb ;  but  most  frequently  from  a  contraction  of  the 
plantar  fascia.  Persons  thus  afflicted  become  unsteady  as  to  main- 
taining the  centre  of  gravity ;  hence,  walk  awkwardly  with  the  toes 
inverted,  and  at  every  step  describe  the  segment  of  a  circle  with 
the  feet.  The  acquired  club-foot  of  adults  but  seldom,  if  ever, 
increases  to  that  of  the  second  stage  of  varus. 


MEANS    OF    CURE   IIST   THE    FIRST   STAGE    OF    TALIPES    VARUS. 

The  condition  of  the  patient  in  this  stage  of  talipes  varus,  in 
children,  is,  to  ensure  careful,  judicious  treatment,  quite  favorable 
for  success.  The  division  of  the  tendo-Achillis  is  advisable,  in 
cases  of  adults,  as  an  auxiliary  to  the  subsequent  treatment.  The 
wearing  of  the  Scarpa  shoe  (modified)  will  suffice  for  children  in 
most  cases  if  properly  applied.  Constant  attention  must  be  given 
to  the  parts  of  the  foot  most  exposed  to  pressure,  and  fresh  lint 
applied  from  time  to  time,  as  the  parts  present  indications  of  inflam- 
mation. This  care  will  facilitate  the  cure ;  as  there  will  then  be  no 
interruption  to  the  extension  of  the  foot  while  the  noAV  formation  of 
tendon  is  yet  in  a  yielding  condition,  as  well  as  when  extension 
alone  is  being  relied  upon. 

When  the  foot  is  restored  to  normal  form,  the  modified  Scarpa 
shoe  should  be  worn  night  and  day  for  a  year  or  eighteen  months. 
During  the  day  an  ordinary  laced  boot  can  be  worn  over  the  shoe — 
the  laced  boot  having  a  broad,  low  heel,  and  fitting  closely  to  the 


66 


Orthop^bia. 


foot.  At  all  times  the  foot  should  be  nicely  secured  in  tlie  steel 
shoe  by  tying  the  heel  down  firmly  in  the  heel-cup  of  the  metal 
shoe,  with  tapes  attached  to  a  pad  placed  on  the  instep  at  its  junc- 
tion with  the  leg.  This  is  most  readily  accomplished  by  passing  the 
tapes  through  an  open  space  left  in  the  heel  of  the  shoe. 


THE  AUTHOR  S   MODIFICATION     OF    SCARPA  S    SHOE,   AND    MODE    OF 
APPLTIXG    IT   IN   THE   TREATMENT   OF   TALIPES   VARUS. 

Fig.  31,  A,  the  encircling  band  for  the  leg,  and  vertical  spring 
attached  to  the  shoe  having  a  limited  movement  by  means  of  an 
extended  point  D,  striking  a  small 
projecting  stud,  thus  keeping  the 
sole  of  the  shoe  at  a  right  angle 
with  the  upright  elastic  curved 
spring.  The  encircling  heel  band 
of  sheet  steel,  forms  a  cup  for  the 
heel,  and  is  set  above  the  sole  about 
a  quarter  of  an  inch,  admitting 
straps  to  pass  through  beneath 
this  baud,  to  be  returned  and  tied 
on  a  cushion  placed  on  the  instep 
of  the  foot.  At  C  the  heel  band 
is  extended  so  as  to  give  ample 
support  to  the  outer  margin  of 
the  foot. 

The  shoe  being  applied  to  the  foot  in  a  case  of  talipes  varus,  the 
heel  is  secured  in  the  cup,  and  the  band  for  encircling  the  leg,  A, 
left  outside  the  leg  until  the  foot  is  secured  by  the  roller  B.  The 
roller  is  seen  to  first  encircle  the  foot  by  a  few  turns,  and  then  at  D, 
reversed  and  passed  under  the  sole ;  thus  a  purchase  is  obtained  for 
everting  the  distal  portion  of  the  foot,  and  secured  by  a  few  turns 
of  the  roller  over  the  foot  and  plate,  the  foot  being  well  protected 
with  some  soft  material  intervening  between  the  plate  C  and  the 
foot.  The  foot  being  now  secured,  the  band  A  is  to  be  passed 
round  the  leg. 

By  the  elastic  force  of  the  vertical  spring  the  tibio -tarsal  normal 
relation  is  eventually  restored,  and  the  meta-tarsal  by  the  reversing 
of  the  roller  on  the  foot  under  the  sole  plate.     And  the  extension 


General  Remarks  on  the  Treatment  of  Talipes.     67 

of  the  tendo-Achillis,  by  means  of  the  instep  strap  and  the  limited 
joint,  admitting  of  motion  to  the  tibio-tarsal  joint.  The  advancing 
of  the  body  concentrates  the  weight  upon  the  front  of  the  foot, 
and  extends  the  gastrocnemius  muscles,  one  of  the  most  important 
steps  in  the  treatment. 

In  the  treatment  of  adults  laboring  under  this  stage  of  talipes 
varus,  with  the  tendo-Achillis  in  a  tense  condition,  a  cure  can  only 
be  accomplished  by  the  section  of  the  tense  tendon;  and  failures 
to  cure,  in  most  instances,  may  be  attributed  to  the  neglect  of  this 
necessary  preparatory  step  in  the  treatment.  Even  in  aged  and 
corpulent  persons,  the  severing  of  the  tendo- Achilles  is  admissible; 
and  is,  in  fact,  the  only  means  of  affording  them  relief  from  the 
painful  contraction  of  that  tendon. 

By  severing  the  tendon,  aged  persons  have  been  relieved  from  a 
decrepit  condition.  Mr.  William  Adams,  in  the  appendix  to  his 
treatise  on  club-foot  (page  368),  gives  the  history  of  a  remarkable 
case  of  a  gentleman  fifty-four  years  of  age,  and  weighing  two 
hundred  and  ninety-four  pounds,  who  had  been  under  the  treat- 
ment of  some  of  the  most  eminent  surgeons  of  Europe  without 
being  benefited  by  their  treatment,  and  who  was  subsequently  cured 
by  him  through  the  severing  of  the  tendo-Achillis  of  both  feet. 

The  modified  Scarpa  shoe  is  the  best  appliance  in  these  cases,  as 
it  can  be  firmly  affixed  to  the  foot  immediately  after  the  operation, 
and,  by  means  of  the  elastic,  curved,  upright  spring,  normal  lateral 
relation  of  the  ankle  joint  is  restored,  and  affords  a  continuous 
support  with  elastic  force  tending  to  overcome  the  excessively  con- 
tracted tissues  of  the  opposite  aspect  of  the  limb.  The  posterior 
muscles  of  the  leg  are  limited  in  their  contractile  efforts  by  the 
limited  joint  of  the  shoe  at  the  ankle,  which,  while  it  admits  of 
motion  in  the  flexors,  at  the  same  time  limits  the  contraction  of 
the  extensor  muscles  of  the  foot.  The  flexors  are  thus  relieved 
from  the  continuous  extension  that  has  partially  exhausted  their 
power  of  contraction,  and  the  firmly  secured  heel  becomes  a  fixed 
point  for  the  accomplishment  of  the  desirable  object  of  flexing  the 
foot  upon  the  leg,  while  a  firm  support  is  given  to  the  outer  margin 
of  the  foot. 

This  extended  surface  of  support  is  of  inestimable  advantage  in 
furnishing  an  extended  jioint  of  hearing,  as  when  limited  to  a  small 
space,  is  a  sure  means  for  the  destruction  of  the  integument  j)ressed 
upon. 


68  Orthopmdia. 

The  general  applicability  of  the  modified  Scarpa  shoe  to  nearly 
all  varieties  of  club-foot  constitutes  it  one  of  the  most  useful  of 
surgico-mechanical  appliances,  requiring  only  experience  and  dex- 
terity in  the  application  of  the  roller  to  have  it  meet  nearly  all  the 
indications  that  may  present  in  the  treatment  of  contortions  of 
the  feet. 


SECOZjTD    stage    of   talipes   varus   AlS^D   TREATMENT. 

In  the  second  stage  of  talipes  varus  the  foot  rests  almost  entirely 
upon  the  outer  edge,  the  os  cuboid  bearing  part  of  the  pressure. 
The  inner  margin  of  the  foot  is  now  more  inclined  to  curve  inward, 
and  the  dorsum  of  the  foot  is  nearly  vertical,  the  external  malleolus 
prominent,  from  the  increased  obliquity  of  the  os  calcis,  and  the 
heel  more  retracted  than  in  the  first  stage,  the  motions  of  the  joint 
more  limited  and  the  whole  foot  less  pliable. 

This  form  of  talipes  varus  is  more  often  the  result  of  paralytic 
seizures,  or  of  acquired  habit  resulting  in  deformity.  Congenital 
cases  frequently  present  for  treatment,  but  never  after  two  years  of 
age;  as  their  contorted  feet  have  then  assumed  the  condition 
belonging  to  the  third  stage. 

Prognosis,  as  to  cure  in  the  second  stage  of  talipes  varus,  may  be 
considered  quite  certain  under  judicious  treatment. 

In  this  stage  of  the  ailment  we  have  the  gastrocnemius,  plantar, 
and  soleus  muscles  considerably  shortened ;  requiring  for  successful 
treatment  the  severing  of  the  tense  tendons  of  one  or  more  of  these 
muscles.  This  preparatory  step  of  course  saves  the  patient  much 
suflFering,  which  Avould  otherwise  result  from  their  continued 
extension. 

The  subsequent  treatment  requires  similar  appliances  to  that  of 
the  first  stage  of  talipes  varus;  only  more  force  is  required,  and  an 
extended  duration  of  time  for  the  cure.  The  points  most  exposed 
to  pressure  are  very  liable  to  excoriation,  and  must  be  defended 
from  pressure  with  Imt,  carefully  prepared  and  used  in  ample  quan- 
tity;  never  permitting  cotton  fibre  in  an  unmanufactured  condition 
to  be  used.  Cotton  fabric  that  has  been  long  worn  and  frequently 
washed,  if  carefully  and  evenly  folded  to  the  thickness  of  a  quarter 
of  an  inch,  and  every  day  opened  up  and  refolded,  will  effectually 
protect  the  parts  from  concentrated  pressure. 


(jrENERAL  REMARKS  ON  THE  TREATMENT  OF  TaLIPES.      gQ 

In  cases  where  excoriation  has  ensued  the  pressure  must  be  di- 
minished and  the  foot,  if  possible,  kept  in  the  brace.  A  dressing  of 
mutton  tallow  apj^lied  once  a  day  to  the  excoriated  parts  affords 
relief  in  nearly  all  cases.  If  more  than  ordinary  inflammation  and 
suppuration  should  supervene,  ordinary  surgical  treatment  must  be 
persevered  in  to  the  relief  of  the  patient,  when  the  former  treatment 
must  be  again  commenced,  and  if  the  tendons,  which  have  become 
tense  during  that  period  of  non-extension,  are  not  again  severed,  it 
is  only  prolonging  the  time  of  treatment  and  hazarding  a  failure  in 
the  perfect  restoration  of  the  foot.  Even  under  more  favorable 
circumstances  the  repetition  of  the  operation  facilitates  treatment, 
and  tends  to  a  more  perfect  cure  than  a  reliance  upon  continued 
extension. 

When  deformity  of  a  foot  has  been  reduced,  all  has  not  been 
accomplished  that  is  required  to  ensure  a  continuance  of  the  normal 
form,  and  more  especially  if  the  patient  is  young  and  the  ailment 
congenital.  The  tendency  to  contortion  remains  and,  if  not  care- 
fully controlled  for  a  year  or  two,  a  relapse  is  sure  to  ensue  to  the 
detriment  of  the  surgeon's  reputation,  as  application  will  then  be 
made  to  some  other  person  to  complete  the  cure. 

In  the  treatment  of  varus  the  "  Scarpa "  shoe,  in  its  modified 
form,  should  be  worn  day  and  night  during  the  period  above  stated. 
As  it  is  worn  tuitM7i  a  shoe  but  little  inconvenience  attends  its  use. 
The  construction  of  the  outer  shoe,  however,  is  of  importance ;  as 
it  should  fit  closely  over  the  metal  shoe,  and  be  made  to  lace  firmly 
only  over  the  malleola  —  lacing  above  impedes  the  circulation. 

We  have  been  thus  minute  in  describing  treatment  of  this  ail- 
ment, and  advising  long-continued  vigilance,  as  it  is  the  most  com- 
mon contortion  of  the  feet  and  apparently  to  the  inexperienced 
practitioner,  the  most  readily  cured ;  being  so  advised  by  the  first 
authority  in  general  surgery,  and  by  what  Mr.  Adams  denominates 
"  erroneous  doctrine  inculcated  by  eminent  authority ;"  as  that  of 
Prof.  Syme,  who  states  that  contortion  of  the  feet  is  curable  by  tlie 
severing  of  the  tendons  alone,  and  without  adjunct  meclianical 
treatment. 

The  experience  of  nearly  forty  years'  practice  in  the  treatment  of 
these  ailments  has  impressed  us  with  the  most  indubitable  evidence 
of  the  fallacy  of  Professor  Syme's  statement,  and  of  the  existing  ne- 
cessity for  the  perseverance  and  extreme  care  we  have  so  repeatedly 
advised,  to  ensure  permanent  relief  in  these  cases  of  contorted  feet. 


70  Orthopjebia. 

It  is  much  to  be  regretted  that  such  inconsistent  statements 
should  be  made  by  so  eminent  authority ;  tending,  as  they  do,  to 
impair  confidence  in  the  treatment,  because  of  the  disappointment 
on  the  part  of  both  patient  and  surgeon.  Not  only  have  practitioners 
of  eminence,  from  their  reliance  upon  so  high  an  authority,  been 
disappointed  and  discouraged  from  the  failures  resulting  from  this, 
but  their  reputations  have  been  seriously  compromised  as,  in  many 
instances,  careful  subsequent  treatment  at  other  hands  has  in  these 
same  cases  effected  a  cure;  and  by  persons  of  usually  limited  attain- 
ment in  the  medical  profession,  to  the  encouragement  of  adventur- 
ous treatment. 

That  eminent  surgeons,  in  the  general  practice  of  surgery,  have 
sufficient  practical  experience,  or  are  disposed  to  devote  their  valua- 
ble time  for  months  to  the  treatment  of  a  patient  laboring  under 
contortion  of  body  or  limbs,  is  not  to  be  expected,  when  a  capital 
operation  requires  only  two  or  three  weeks'  time,  and  results  in 
relief  from  much  suffering,  and  often  a  valuable  life  saved.  Hence 
this  is,  imperatively,  a  special  department  of  surgery,  too  frequently 
assumed  by  persons  of  very  limited  knowledge  in  their  profession, 
because  of  the  required  patience  and  labor  essential  to  insure  suc- 
cessful treatment  which  they  can  well  afford. 

This  is  to  be  regretted,  as  orthopaedic  surgery,  to  insure  success  in 
treatment,  requires  absolutely  scientific  attainment  in  anatomy, 
physiology  and  surgery;  the  comparatively  simple  operation  of 
applying  counteracting  force  to  the  cure  of  deformity  requires  an 
intimate  knowledge  of  anatomy,  and  the  improvement  of  the 
abnormal  conditions  of  the  muscles  demands  a  more  than  superficial 
knowledge  of  physiology,  while  the  arresting  of  any  inflammatory 
condition  that  may  be  induced  from  pressure  under  ordinary  cir- 
cumstances properly  applied,  upon  parts  deficient  in  vitality,  requires, 
in  some  cases,  even  more  than  ordinary  skill  in  surgery.  Therefore 
inexperienced  surgeons  who  will  assume  the  treatment  of  this  class 
of  ailments,  performing  only  the  initiatory  step  of  severing  the  tense 
tendons  and  delegating  the  subsequent  treatment  to  instrument 
makers,  inexperienced  students,  or  nurses,  are  seriously  accountable 
to  their  patients  for  dereliction  of  duty. 


General  Remarks  on  the  Treatment  of  Talipes.     71 


TniKD    STAGE    OF   TALIPES   VARUS. 

The  condition  of  the  foot  in  this  stage,  from  continued  use  in  an 
unfavorable  position,  becomes  greatly  contorted.  The  anterior  por- 
tion presents  the  inner  margin,  upward  and  inclining  inward,  the 
plantar  aspect  vertical,  and  having  deep  fissures.  The  dorsum  is 
rounded  and  somewhat  irregular,  because  of  the  partial  displace- 
ment of  the  tarsal  bones.  About  the  position  of  the  internal  mal- 
leolus appear  slight  corrugations  of  the  skin,  presenting  a  seeming 
outline  of  the  inner  margin  of  the  heel.  The  posterior  is  round 
and  tense,  from  which  arises  an  acute  prominence  of  the  tendo- 
Achillis  extending  upward.  The  base  of  support  is  represented 
by  large  bursee  with  hardened  surface,  an  apparent  provision  of 
nature  to  prevent  injury  to  the  bones  and  ligaments  subjected  to 
this  undue  pressure,  the  result  of  the  abnormal  condition.  How- 
ever, this  is  disposed  to  inflammation,  thereby  subjecting  the  patient 
to  much  suffering. 

Both  feet  being  affected,  the  patient,  in  walking,  carries  the 
anterior  of  each  foot  alternately  over  the  other  with  a  semi-circular 
motion,  and,  from  the  limited  base  of  support,  is,  of  necessity,  com- 
pelled to  keep  constantly  in  motion  when  attempting  to  sustain  the 
body  in  an  erect  position,  exacting  a  more  extraordinary  demand 
upon  the  muscles  of  the  thigh  for  sustaining  force  than  in  the  nor- 
mal condition  of  the  feet,  tending  to  an  increase  of  strength.  The 
leg  below  the  knee  is  attenuated  to  mere  skin  and  bones,  present- 
ing the  appearance  of  a  very  low  degree  of  vitality,  subject  to  abra- 
sions of,  at  times,  alarming  aspect,  and  difficult  to  heal.  The  great 
stress  and  tension  upon  the  muscles  thus  compressing  the  blood- 
vessels, nutrition  is  impeded  in  the  soft  tissues.  The  vessels,  being 
less  impeded,  sustain  the  growth  of  bone,  as  it  is  but  seldom  that 
we  find  a  club-footed  limb  shorter  than  its  fellow  in  a  normal  con- 
dition. 


TEEATMENT   OF   THIED   STAGE    OF   TALIPES   VAEUS. 

In  this  stage  of  deformity  of  the  foot,  many  ligaments  and  several 
tendons  are  at  fault,  as  well  as  the  plantar  aponeurosis,  and  to 
obtain  a  tolerable  prognosis,  requires  careful  examination  as  to  their 
influence  in  retaining  the  foot  in  its  contorted  condition,  when  it 
may  be  found  that  the  severing  of  one  or  more  of  the  shorter  ten- 


72  Orthop^dia. 

(Ions  may  suffice  in  redressing  the  deformity.  The  tense  condition 
of  the  tendo-Achilhs  will  indicate  the  necessity  of  its  section,  and, 
in  some  cases,  will  be  all  that  will  be  required  in  the  way  of  tenot- 
omy for  a  tolerable  restoration  of  the  contorted  foot,  i.  e.,  to  enable 
the  patient  to  jjlace  a  portion  of  the  plantar  surface  to  the  ground, 
a  very  great  relief  Avhen  afforded. 

There  are  cases,  and  not  a  few,  where  treatment  has  been  deferred 
to  a  late  period  (and,  if  congenital,  most  unfavorable  cases  for 
treatment).  From  dental  paralysis  and  constant  exercise  tipon  the 
impaired  limb  or  limbs,  has  resulted  in  the  third  stage  of  talipes 
varus.  The  most  serious  impediment  to  the  redressing  of  the  ail- 
ment is  the  shortened  plantar  fascia,  though  this  obstacle  may  be 
readily  detected  by  careful  examination,  when  an  apparent  thick- 
ened mass  of  tissues,  limited  in  breadth  at  the  middle  of  the  con- 
cave arch,  and  quite  tense,  is  found  to  extend  from  the  base  of  the 
OS  calcis  to  the  distal  extremity  of  the  metatarsal  bones.  The  section 
_of  this  tense  substance,  the  tendo-Achillis  being  previously  severed, 
will  be  the  only  requirement  for  the  interference  of  the  knife,  to 
insure  a  sufficient  preparatory  condition  for  relief  by  judicious 
subsequent  treatment,  in  nine-tenths  of  the  cases  that  will  come 
into  the  hands  of  the  surgeon. 

In  extraordinary  cases,  the  division  of  both  the  tibialis  posticus 
and  anticus  tendons  may  be  indicated,  to  the  relief  of  the  impedi- 
ment of  the  contorted  condition  of  the  foot ;  but  such  cases  seldom 
result  in  a  perfect  cure ;  the  feet  have  become  so  fixed  in  their  abnor- 
mal condition,  from  the  adaptation  of  the  bones,  ligaments  and 
aponeurotic  shortening,  that  the  division  of  the  tendons  will  not,  in 
all  cases,  be  sufficient  for  the  restoration  of  the  normal  form,  the 
ligaments  being  primarily  at  fault  and  so  deeply  situated  as  to  pre- 
clude the  possibility  of  severing  them  with  safety.  Much  improve- 
ment, however,  may  be  obtained  from  perseverance  in  manipulation 
and  suitably  constructed  appliances. 


CAUSES   OF   VALGUS,    AND    CONDITION"   OF   THE    BONES. 

Valgus  is  the  result  of  some  local  impairment  of  the  sustaining 
tissues,  in  nearly  all  cases  that  present  for  treatment,  though  an 
exceptional  case  of  congenital  valgus  will  at  times  occur.  It  is 
generally  the  effect  of  some  continued  extending  force  upon  the 


General  Remarks  on  the  Treatment  of  Talipes.     73 

plantar  aponeurosis,  as  that  of  exercising  too  freely  in  dancing  Avlien 
young,  or  high  heeled,  thin  soled  shoes,  when  worn  by  delicate 
children  or  feeble  adults;  sprains  and  injuries  resulting  from  jump- 
ing, or  falling  on  the  feet  from  a  great  height ;  partial  paralysis, 
preternatural  laxity  of  the  ligaments  of  the  foot  and  ankle,  as  in 
scrofulous  or  rickety  children. 

The  ligaments  and  muscles  implicated  in  valgus  have  been  stated. 
The  astragalus  is  rotated  on  its  lo7ig  axis  inward,  and  there  is  a 
separation  of  the  head  from  the  cavity  of  the  naviculare,  the  latter 
being  depressed,  and  its  prominence  most  marked,  appearing  as  the 
key  of  the  arch  displaced  to  the  depression  of  the  instep.  The  os 
calcis  is  rotated  on  its  sliort  axis  and  obliquely  outward,  and  its 
posterior  extremity  extremely  elevated.  The  cuneiform  bones  are 
closely  pressed,  and  are  nearly  in  situ  ;  the  phalanges  assume  a  more 
or  less  vertical  position  as  the  contortion  increases,  inducing  a  most 
painful  condition,  limiting  the  patient's  ability  to  take  walking 
exercise  to  a  much  greater  degree  than  that  of  talipes  varus.  It  is 
the  next  most  common  variety  of  talipes,  and  known  by  the  term 
valgus,  and  characterized  by  the  contortion  tending  outward,  the 
feet  having  become  flattened  from  the  yielding  of  the  plantar  fascia ; 
the  bearing  being  upon  the  entire  plantar  surface  inclining  to  the 
inner  edge,  and  tending  to  an  increasing  depression  in  front  of  the 
internal  malleolus,  which  becomes  quite  prominent,  with  a  round- 
ness increased  from  the  advanced  position  of  the  naviculare.  This 
is  the  first  stage  of  valgus. 


TREATMENT   OF   TALIPES   VALGUS. 

For  the  relief  of  talipes  valgus,  tense  tendons  present  that  require 
to  be  severed.  In  cases  of  moderate  contortion,  it  will  suffice  to 
sever  the  peronei  and  extensor  longus  tendons  ;  but  in  some  more 
severe  cases,  the  tendo-Achillis  will  require  severing  as  well  as  that 
of  the  tibialis  anticus  and  extensor  pollicis. 

The  operation  can  be  performed  by  determining  the  location  of 
the  extensor  longus  in  front  of  the  external  malleolus,  and  close  in 
to  the  ankle  joint  where  it  will  be  found  prominent.  Care  must  be 
taken  in  inserting  the  knife  flat  beneath  the  tendons  to  be  severed. 


74  Orthop^dta. 

and  that  it  reaches  only  to  the  breadth  of  the  tendon  to  be  divided; 

by  this  precaution,  the  anterior  tibial  artery  can  be  avoided. 

Arteries  and  nerves  are  but  seldom  wounded  when  proper  pre- 
caution is  taken  ;  first,  to  apply  resisting  force  to  the  tense  tendon, 
rendering  it  more  prominent,  then  placing  the  forefinger  of  one 
hand  upon  the  tendon  and  carefully  inserting  the  knife  beneath, 
limiting  tlie  cutting  edge  to  the  breadth  of  the  tendon.  This  pre- 
caution will  apply  to  the  severing  of  nearly  all  tense  tendons. 
There  is  an  exception,  circumstantial,  however,  in  the  case  of  section 
of  the  biceps  tendon  when  shortened  at  the  knee.  The  perineal 
nerve  has  been  severed  from  indiscretion  or  want  of  practical 
knowledge.  In  cases  of  long  standing,  the  nerve  is  shortened  as 
well  as  the  tendon,  and  cannot  be  avoided,  even  when  the  tendon 
is  cautiously  severed;  but  from  the  shortened  condition  of  the 
nerve  also,  it  presents  a  tense  margin,  and  the  operator,  supposing 
that  he  has  not  severed  the  entire  tendon,  again  inserts  the  knife 
and  severs  the  nerve.  The  result  of  this  is  a  paralysis  of  the  pero- 
neus  and  extensor  muscles,  terminating  in  talipes  equino-varus. 

The  first  stage  of  valgus  is  readily  relieved  by  a  steel  spring  hav- 
ing an  elevation  to  correspond  with  the  normal  width  of  the  foot, 
and  secured  in  the  shoe  at  the  heel  by  two  or  three  screws ;  the 
anterior  portion  left  free  to  glide  upon  the  inner  sole  of  the  shoe. 
The  spring  is  constructed  of  thin  sheet  steel,  and  the  arch  raised 
with   the  hammer.     The  form,  when  cut  Fig.  32. 

out  of  sheet  steel,  is  as  represented  in  Fig- 
ure  32. 

No.  1  is  the  form  when  cut  out  of  the 
sheet  of  steel,  and  No.  2  represents  the 
arch,  3  showing  the  outer  edge,  which  has 
been  drawn  into  form  by  the  raising  of  the 
arch  2.  No.  1.  No.  3. 

This  spring  should  be  worn  for  eighteen  months  or  two  years. 
This  has  been  our  common  treatment  for  over  twenty  years,  and 
when  carefully  persevered  in,  has  never  failed  to  cure  valgus  in  the 
incipient  stage  and  even  in  advanced  conditions  —  sometimes  where 
other  treatment  had  been  objected  to,  as  the  spring  can  be  worn  in 
the  ordinary  shoe.  If  in  the  first  stage  of  valgus,  the  tendency  is 
not  arrested,  greater  exaggeration  ensues;  the  bearing  of  the  foot 
inclines  to  the  anterior  and  inner  edge,  the  heel  in  some  cases  being 
elevated  outAvard  from  a  shortening  of  the  gastrocnemius  and  soleus 


General  Remarks  on  the  Treatment  of  Talipes.    75 

muscles,  the  plantar  aspect  becomes  convex,  the  internal  malleolus 
and  the  scaphoid  quite  prominent,  while  the  dorsum  presents  a 
complete  depression  of  the  arch.  At  this  stage  of  the  ailment,  the 
patient  suffers  much  pain  in  attempting  to  walk,  and  has  but  a 
very  limited  control  over  all  efforts  in  that  direction. 


TKEATMENT   OF   EXTREME    CASES    OF   TALIPES   VALGUS. 

Oases  that  have  advanced  to  an  extraordinary  degree  of  contortion 
have  the  following  tendons  shortened : 

The  extensor  longus  and  peronei  will  be  found  prominent  and  tense 
in  front  of  the  malleolus  externus,  and  to  facilitate  the  treatment 
should  be  severed  before  any  effort  at  extension,  by  means  of  appa- 
ratus, is  made ;  as  the  use  of  the  latter  without  the  former  preparatory 
step  will  only  encourage  the  patient  to  prolong  the  treatment  by  per- 
sisting in  wearing  the  extension  apparatus  in  hopes  of  a  cure  result- 
ing without  submitting  to  tenotomy  —  an  operation  greatly  dreaded. 
In  most  cases  the  tendo-Achillis  will  be  found  so  tense  as  to  like- 
wise require  division.  However,  this  may  be  deferred  until  after 
the  section  of  the  above  mentioned  tendons  which  in  many  cases, 
will  be  found  all-sufi&cient  for  relief  of  the  foot. 

The  extension  apparatus  is  that  of  the  modified  "  Scarpa "  shoe 
used  in  cases  where  there  has  been  a  shortening  of  the  tendo-Achilles. 
The  ankle  joint,  in  the  apparatus,  being  limited  precisely  as  in  the 

treatment  of  talipes  varus;  the  only 
change  being  that  of  having  the  up- 
right spring  applied  to  the  inner  side 
of  the  leg,  tending  the  foot  inward 
and  sustaining  it  at  a  right  angle 
with  the  leg,  as  well  as  permitting  a 
free  movement  of  the  foot  upward. 
[See  Fig.  33,  a  varus  shoe  having  the 
spring  reversed.]  A,  the  inner  mar- 
gin of  the  foot;  B,  the  metal  sole 
plate  ;  C,  the  foot  secured  by  the  in- 
step pad  and  tapes.]  This  movement 
you  should  instruct  the  patient  to 
perform  by  placing,  the  front  of  the 
foot  on  some  fixed  object  which  would 


Fig.  33. 


76 


Orthopjedta. 


allow  the  heel  to  be  depressed.     This  will   afford  an  exercise  of 
great  value  in  all  cases  where  the  gastrocnemius,  soleas  and  plantaris 
muscles  are  in  a  shortened  condition,  and  even  in  some  cases,  obvi- 
ates the  necessity  of  severing  the  tendo-  m^.U. 
Achillis. 

The  method  of  application  of  the 
modified  '•'  Scarpa "  shoe  is  represented 
in  Fig.  34.  In  this  engraving  the  front 
of  the  foot  is  limited  in  its  upward  tend- 
ency, as  in  nearly  all  cases  of  valgus  the 
extensors  of  the  foot  are  paralyzed.  It 
will  be  observed  that  the  joint  A  can  be 
readily  reversed  from  that  constructed 
for  extending  the  gastrocnemius,  soleus 
and  plantar  muscles.  The  limited  joint 
sustains  the  foot  at  a  right  angle  with  the  ^ 

leg,  the  heel  being  fixed.  °        ^ 

To  apply  the  roller  to  the  foot,  a  few  turns  should  be  taken  over 
and  under  (B),  and  then  pass  under  the  plate  in  a  reversed  direction 
(C),  by  which  means  the  everted  foot  will  be  drawn  on  the  plate,  there 
being  a  sufficiency  of  the  roller  at  D  to  secure  the  foot  in  its  place. 

This  having  been  completed,  the  curved  elastic  spring  (E)  is  to 
be  adjusted  by  passing  the  attached  broad  padded  band  around  the 
leg  and  the  strap  buttoned,  which  completes  the  dressing —  the  foot 
having  previously  been  protected  at  the  points  of  pressure  by  means 
of  lint  and  the  rollers. 

This  is  the  first  dressing,  which  is   to  be  continued  during  the 
reparative  process  of  the  several  tendons,  or,  for  about  three  months, 
when  it  will  be  found  that  the  foot  is 
relieved  from  the  everted  condition,  and 
presents  only  the  depressed  instep. 

For  the  elevation  of  the  instep,  we 
have  a  piece  of  cork  properly  shaped  for 
that  purpose  and  attached  upon  the  sole- 
plate  of  the  '•'  Scarpa "  shoe,  as  first  ap- 
plied. (See  Figure  35.)  A  well-padded 
cushion  (A)  is  secured  by  a  plate  on  the 
inner  side  of  the  joint  at  the  ankle.  The 
€ork  is  attached  on  the  foot  plate  (B), 
and  a  roller  secures  the  ball  of  the  foot 


Fig.  35. 


General  Re3/arks  on  the  Treatment  of  Talipes.    77 


ri£(.36. 


firmly  to  the  plate  —  the  heel  being  firmly  held  by  the  tapes  tied 
on  the  instep. 

The  patient,  in  the  second  stage  of  the  treatment  is  now  advised 
to  Avear  over  the  "  Scarpa"  shoe,  a  laced  boot  Avith  a  low  heel,  and 
to  continue  wearing  the  brace,  day  and  night,  for  at  least  eighteen 
months;  then  be  relieved  to  the  wearing  of  a  shoe  prepared  with 
the  elastic  spring,  as  worn  in  the  treatment  of  talipes  valgus  in  its 
incipient  stage  and  represented  in  Fig.  32. 

There  are  cases  of  talipes  valgus,  where  the  tendo-Achilles  and 
soleus  muscles  are  so  paralyzed  as  to  tend  to   a  depression  of  the 
heel,   and     properly    termed    calcaneo-valgus. 
(See  Fig.  36.) 

The  foot,  in  this  condition,  is  attended  with 
much  inconvenience  to  the  individual  when 
walking.  When  an  effort  is  made  to  take  a 
step  the  anterior  of  the  foot  is  involuntarily 
extended,  and  to  avoid  tripping  the  foot  has  to 
be  raised  higher  than  ordinary,  and  the  inner 
side  of  the  foot  advanced  —  the  whole  limb  be- 
ing more  or  less  rotated  outward ;  the  heel 
striking  the  ground  first  and  the  front  of  the 
foot  coming  down  mechanically  when  the  at- 
tempt is  made  to  advance  the  other  foot. 

For  the  relief  of  this  condition  of  the  foot  the  modified  "  Scarpa" 

shoe  is  most  applicable,  having  the  joint  so  limited  as  to  admit  of 

Fig.^i.  elevating  or  depressing  the  extremity  of 

the  anterior  of  the  foot  only  two  inches 

as  shown  in  Fig.  37. 

The  construction  of  the  limited  joint  is 
seen  at  A,  and  the  foot  secured  to  the  plate 
by  means  of  a  roller  at  B.  The  vertical 
spring  C  is  of  only  sufficient  strength  to 
support  the  foot  in  normal  position,  per- 
mitting lateral  motion  in  the  ankle  joint 
from  its  elasticity. 

The  modified  '•'  Scarpa  "  shoe  should  be 
worn  day  and  night,  and  during  the  day 
within  an  ordinary  shoe.     At  stated  periods 
of  about  twelve  hours,  the  foot  ought  to  be 
stripped  and  the  tendo-Achillis    and  soleus  carefully  manipulated 


78  Orthop^dia. 

for  ten  or  fifteen  minutes ;  then  have  strychnine  ointment  applied  to 
these  muscles,  twelve  grains  to  the  ounce  of  simple  cerate,  care  being 
taken  to  cleanse  the  surface  with  warm  water  and  soap,  or  an  alkali, 
previous  to  each  application  of  the  ointment. 

Faradization  is  of  much  service  applied  to  the  paralyzed  muscles, 
when  the  foot  is  thus  supported,  and  decidedly  injurious  when  not 
supported,  as  its  tendency  is  to  shorten  the  flexor  muscles  and 
increase  the  contortion,  since  it  is  impossible  to  localize  the  elec- 
trical influence  sufficiently  to  obviate  this  tendency.  The  applica- 
tion of  all  modifications  of  electricity  is  objectionable  under  the 
above  stated  circumstances,  because  of  its  increasing  the  contractile 
power  of  the  muscular  tissue,  and  it  cannot  be  limited  in  its 
influence  to  one  or  more  paralyzed  muscles. 

All  the  muscles  of  the  limb,  if  not  of  the  whole  body  and  limbs, 
are  influenced  by  induction,  when  electricity  is  applied  to  any  part 
of  the  system.  When  applied  to  the  foot  or  hand  of  a  delicate 
female,  it  has  been  known  to  induce  the  menstrual  floAV.  The  con- 
centrated form  of  electricity  produces  a  powerful  stimulant  effect 
analogous  to  that  of  acupuncture,  and  is  then  diffused  through  the 
medium  of  the  circulatory  fluids,  they  being  decided  conductors 
of  electricity. 


TALIPES   EQUIIfUS. 

Of  the  various  contortions  of  the  foot,  those  within' the  category 
of  talipes  equimis  are  the  most  simple,  the  first  indication  being  an 
inability  to  flex  the  anterior  of  the  foot  to  Fig.38. 

a  right  augle  with  the  leg,  relief  for  which 
is  afforded  by  the  wearing  of  a  high-heeled 
shoe,  indicating  a  shortened  condition  of  the 
extensor  muscles  of  the  foot,  (See  Fig.  38.) 

When  the  patient  is  not  relieved  of  this 
restricted  movement  of  the  foot,  it  increases 
to  a  most  extraordinary  condition  of  contor-     _        ^  ^  _^ 

tion  ;  assuming  more  or  less  of  the  two  forms  ^Wr^^ 

of  contortion  just  treated  of,  and  in  partak- 
ing of  one  or  the  other,  is  denominated  equino-varus  or  valgus. 

The  most  marked  character  of  talipes  equinus  is  the  elevation  of 
the  heel  and  tendency  to  vertical  position  of  the  metatarsus,  con- 
centrating the  entire  bearing  upon  the  extremities  of  the  metatarsal 


General  Remarks  on  the  Treatment  of  Talipes.    79 


bones,  which  leads  to  an  increase  of  breadth  in  this  part  of  the 
foot,  and  very  decided  contraction  of  the  plantar  fascia. 

There  are  extraordinary  cases  of  this  ailment,  the  result  of 
paralysis,  limited  to  the  flexors  of  the  foot. 

The  individual  thus  afflicted  walks  upon  the  dorsum  of  the  toes 

and  ends  of  the  metatarsal  bones,  and  from  long  continued  stress 

Figs.  39  and  40.  advances   the  bearing  on 

the  dorsum  to  the  tarsus, 
(See  Figs.  39  and  40,  for 
representation  of  this  con- 
dition.) 

The  distinguishing  fea- 
ture in  talipes  equinus  re- 
sulting from  paralysis  of 
the  flexors,  is,  that  there 
is  not  the  tense  and  promi- 
nent elevation  of  the  ten- 
do- Achillis,  as  in  that  of 
other    influences    tending 
to   this   contortion;   hence,  it  will   be   observed  that  the    heel   is 
round,  full  and  prominent;  indeed,  the  os  calcis  is  in  a  horizontal 
position,  or  very  nearly  so. 

Authorities  differ  much  as-to  the  origin  of  this  ailment,  all  agree- 
ing, however,  that  cases  of  congenital  talipes  equinus,  compared 
with  the  non-congenital,  are  extremely  rare.  Mr.  Tamplin,  with 
all  his  large  experience,  expresses  a  doubt  as  to  the  congenital  origin 
of  the  ailment.  Dr.  Little,  of  London,  is  positive  in  having  seen 
two  cases  out  of  the  many  that  he  has  treated.  Mr.  Broadhurst 
believes  he  has  seen  one  or  two  in  his  extensive  orthopsedic  practice. 
Mr.  William  Adams  believes,  from  report,  which  he  considers  worthy 
of  reliance,  in  three  cases,  which  he  has  classed  as  congenital 
talipes  equinus,  and  these  three  are  out  of  tUi^ee  thousand  cases  of 
different  kinds  of  deformities  that  were  treated  by  the  late  Mr. 
Lonsdale  and  himself.  Truly  a  limited  number,  and  not  very 
positive  proof  that  they  were  congenital  ! 

Mr.  Adams,  in  treating  of  the  pathology  of  this  ailment,  says  : 
"  Talipes  equinus  is,  Avith  very  rare  exceptions,  a  non-congenital 
affection.     It  is  often  claimed  to  be  of  congenital  origin  by  parents, 
but  upon  close  inquiry  we  generally  learn  that  the  symptoms  were 


80  Orthop^dta. 

not   observed  until   the   child   had   began   to   put  its  feet  to  the 
ground." 

This  agrees  with  our  experience,  as  we  have  never  had  positive 
assurance  of  a  single  case  of  congenital  taliyes  equinus  during  a 
practice  i)i  ortliopcedic  surgery  of  nearly  thirty  years. 


COXTRACTIOX  OF  THE  PLAXTAR  APONEUROSIS. 

The  condition  of  the  foot  when  contorted  by  the  plantar  aponeu- 
rosis, having,  from  long  duration,  become  inordinately  shortened, 
is  such  that  treatment  by  means  of  the  improved  "Scarpa"  shoe, 
would  be  very  slow  indeed,  the  shoe,  in  some  cases,  requiring 
to  be  worn  for  years  to  accomplish  a  perfect  cure.  This  is  because 
of  the  fixed  or  unyielding  means  of  extension  thus  employed,  and 
which  is  never  so  eflFectual  as  elastic  force,  or  motion  in  opposition 
to  the  resistance.  The  foot  placed  upon  the  plantar  plate  of  the 
'•  Scarpa  "  shoe,  which  is  unyielding,  and  an  effort  made  to  extend 
the  plantar  fascial  tendons  and  ligaments,  by  pressure  made  upon 
the  instep,  the  resistance  is,  as  in  that  of  all  fixed  apparatus  for  the 
redressing  of  contortions  of  the  body  or  limbs,  to  be  compared  to 
force  made  by  means  of  screws  and  cog-wheels.  This  fixed  power 
induces  pain,  the  result  of  which  is  an  irritable,  unyielding  condi- 
tion of  the  muscles  in  which  it  is  desirable  to  effect  permanent 
extension  to  a  limited  degree,  and  yet  not  impair  their  normal  func- 
tions. Elastic  force  or  limited  motion  has  not  the  tendency,  as  has 
fixed  extension,  even  of  a  moderate  degree,  to  excite  an  irritable  con- 
dition of  the  extended  muscles  or  other  tissues. 

The  extension  of  muscles  and  ligaments  by  elastic  force  is 
not  a  new  discovery,  if  we  may  credit  what  is  stated  of  Scarpa's 
visit  to  Tiphaisne's  house  in  Paris,  in  1781,  where  he  made  the  dis- 
covery that  elastic  steel  springs  were  used  by  that  then  noted  man, 
for  the  cure  of  club-foot,  and  which  had  been  kept  a  secret  from 
the  public,  except  in  the  single  instance  of  his  remark  to  Scarpa 
that  "nature  will  not  yield  to  violence,  but  only  to  gradual  force." 
From  this  intimation,  coupled  with  his  discovery  of  the  steel 
springs,  Scarpa  is  said  to  have  designed  his  club-foot  shoe. 

The  ordinary  "  Scarpa  "  shoe  is  not  all  of  the  apparatus  we  have 


Fig.  41. 


Gen-eral  Remarks  on  the  Treatment  of  Talipes.     31 

relied  upon  for  the  redressing  of  contortions  of  the  feet;  nor 
did  the  inventor  rely  solely  upon  it.  He  constructed  a  shoe 
admirably  adapted  to  the  elongating  of  the  plantar  aponeurosis  by 

means  of  elastic  force,  a  modification  of 
which  we  have  made  for  this  purpose  as 
represented  in  Fig.  41. 

Fig.  42.  The  spring  as  applied  to  the 
foot,  and  secured  with  the  roller,  being 
intended  to  be  worn  within  the  shoe, 
Fig.  41. 

Fig..  42  represents  the  plate  before  it  is 
applied  to  the  foot  —  the  anterior  portion 
curved  upward;  but,  being  very  elastic 
and  nicely  tempered,  it  yields  to  the 
pressure  of  the  foot. 

Scarpa's  apparatus  for  extending  the 
plantar  aponeurosis  consisted  of  a  plantar  plate  and  cup  for  the 
heel,  with  an  elevating  spring  attached  on  the  under  side  of  the 
plate  about  one-third  the  distance  from  its  anterior  extremity. 
This  made  the  apparatus  objectionable  since,  because  of  its  cum- 
brous proportion,  it  could  not  be  worn  within  a  shoe. 

The  late  Prof.  Mutter,  of  Philadelphia,  devised  a  shoe  somewhat 
similar  to  this  (Scarpa's)  by  having  the  plantar  plate  rivited  into  the 
heel  of  a  common  laced  boot,  open  to  the  toe,  and  attaching  under 
the  anterior  portion  of  the  plantar  plate,  an  elevating  spring  that 
rested  upon  the  inner  surface  of  the  sole  of  the  shoe,  with  both 
ends  curved  so  as  to  glide  easily  there;  the  centre  of  the  spring 
being  elevated  to  the  plantar  plate.  This  ingeniously  constructed 
shoe  was,  however,  intended  by  this  most  excellent  orthopsedist*  to 
produce  extension  of  the  extensor  muscles  by  elasticity  in  the  ante- 
rior portion  of  the  foot.  That  this  shoe  made  a  very  decided 
impression  upon  the  plantar-fascia  there  cannot  be  a  doubt  enter- 
tained. The  appliance  as  we  have  modified  it  is  worn  with  more 
comparative  comfort  to  the  patient,  being  much  less  cumbrous  in 
the  shoe,  and  by  no  means  so  objectionable  in  appearance  as  Dr. 
Mutter's  appliance.  It  is  of  great  importance  in  the  treatment  of  a 
patient,  to  have  appliances,  when  completeness  will  admit,  of  the 
construction  to  meet  the  indications  that  present;  to  have  them  con- 


*  Lectures  published  by  Thos.  D.  Mutter,  18;:39,  p.  59. 


82  Or  tmofjedta. 

cealed  from  observation.     The  patient  will  be  more  reconciled  to 
their  use,  and  to  the  more  favorable  progress  in  treatment. 


CAUSES    OF   TALIPES   EQUINUS. 

First :  Long  experience  has  confirmed  the  opinion  that  talipes 
equinus  is  most  frequently  the  result  of  paralysis  induced  during 
dentition,  and  limited,  mainly,  to  the  flexor  muscles.  The  extensor 
muscles  being  thus  liberated  from  their  normal  tension  shorten 
upon  themselves  to  a  quiescent  or  persistent  state  that  results  in  a 
pathological  derangement  of  tonic  fixedness,  limiting  the  demand  for 
nutrition,  as  well  as  the  recuperative  tendency  in  the  flexors,  by 
keeping  them  in  their  extended  position.  The  position  of 
the  foot  during  sleep,  together  with  the  weight  of  the  bed-clothes 
upon  the  extended  foot,  during  the  night,  of  many  hours  duration, 
contributes  largely  to  the  aggravation  of  the  ailment. 

Second:  There  is  but  a  comparatively  limited  number  of  cases 
attributable  to  spastic  contractions,  the  supposed  result  of  convul- 
sions, occurring  before  or  immediately  after  birth,  and  affecting 
nearly  all  the  muscles  of  the  body,  indicating  cerebral  implication. 
The  locomotion,  for  the  want  of  co-ordination  between  mind  and 
muscle,  in  such  cases  is  performed  with  apparent  difficulty  and  vio- 
lent eff'ort,  because  of  inability  to  control  the  desired  movement  of 
feet  or  hands  ;  walking  upon  the  anterior  portion  of  the  feet  with 
an  irregular  effort  of  both  to  maintain  the  erect  position  —  a  staff 
being  of  no  use  because  of  an  inability  to  make  it  available  by  the 
use  of  the  hands. 

Third :  Scrofulous  ailments  result  in  talipes  equinus.  Inflam- 
mation resulting  in  abscesses  is  another  cause  of  the  gastrocnemius 
muscles  terminating  in  structural  impairment,  and  in  some  cases  of 
the  joint  and  the  muscles  becoming  atrophied. 

Fourth :  UnfavoraUe  positio7i  of  the  foot.  To  relieve  pain  from  any 
cause  is  liable  to  become  a  habit  resulting  in  contortion,  and  most 
frequently  that  of  talipes  equinus.  By  persistent  position  atrophy 
is  induced  in  the  muscular  and  ligamentous  tissues;  and  in  addi- 
tion to  the  shortened  condition  of  the  triceps  surce  is  that  of  the 
plantar  aponeurosis.  Wounds  and  bruises  are  a  common  cause  of 
this  ailment,  and  may  be  classed  as  traumatic. 


General  Eemaeks  on  the  Treatment  of  Talipes.    83 

These  several  causes  produce  similar  pathological  effects;  struct- 
ural changes  in  the  affected  tissues,  which  are  of  less  serious  import 
in  regard  to  treatment  than  the  three  first  described,  with  the 
exception  of  the  complete  impairment  of  a  nerve  or  great  extent  of 
injury  to  the  muscles. 

The  prognosis  in  regard  to  the  cure  of  talipes  equinus  may  be 
considered  as  favorable  in  all  cases  Avhere  anchylosis  has  not  taken 
place,  as  in  complication  of  synovitis  with  that  of  shortened  mus- 
cles. Infiltration  of  the  areolar  tissue  immediately  surrounding  the 
joint  having  resulted  in  structural  lesion,  will  somewhat  retard  pro- 
gress, but  never  presents  an  insurmountable  difficulty. 


Fig.  43. 


TKEATMEXT    OF   TALIPES   EQUINUS. 

The  primary  treatment  of  the  four  known  causes  of  talipes  equi- 
nus has  been  the  one  preparatory  step  that  we  have  considered  the 
most  favorable  to  the  patient  in  regard  to 
the  mitigation  of  suffering  induced  by 
efforts  to  overcome  the  contortion.  And 
the  one  cause,  in  more  than  a  majority  of 
cases,  has  been  the  result  of  infantile  par- 
alysis (as  described  in  the  first  division). 
This  step  has  been  to  sever  the  tendo- 
AchiUis,  the  subsequent  treatment  con- 
sisting in  that  of  placing  the  limbs  in  a  sup- 
Fig.  44.  porting    frame, 

as    represented 
in  Fig.  41. 

Fig.  43.  Two  upright  bars  (A),  attached 
to  the  sandal  by  means  of  a  limited  joint 
(B).  At  C  the  instep  pad  and  tapes  are 
represented,  by  means  of  which  extension 
of  shortened  muscles  can  be  made. 

Figure  44  represents  the  foot  in  the  sup- 
porting frame  A,  the  heel  depressed ;  the 
anterior  of  the  foot  resting  upon  the  sole- 
plate  (B),  and  the  foot  secured  by  the  in- 
step-pad and  tapes  as  shown  at  C. 

It    will   be   observed   that  the   heel  is 


,84  OrTHOPjEDIA. 

gradually  brought  doAVii  by  means  of  the  iustep-pad  and  tapes  — 
care  being  taken  to  protect  all  parts  that  may  be  exposed  to  pres- 
sure, and  more  especially  in  these  paralytic  cases,  as  vitality  is  very 
limited,  and  consequently,  the  parts  infringed  upon  disposed  to 
serious  ulceration,  tending  to  an  erysij^elatous  condition  of  the  foot 
and  leg.  A  moderate  extension  is  all  that  is  required  after  the  seo 
tion  of  the  tendo-Achillis  in  cases  the  result  of  paralysis  of  the 
flexor  muscles,  or  the  severing  of  the  plantar  aponeurosis  alone  (the 
extensors  not  being  greatly  implicated),  although  of  several  years 
duration.  With  gentle  force  gradually  applied,  the  foot  will  settle 
down  to  the  plantar  plate,  and  when  this  is  accomplished,  careful 
attention  must  be  exercised  in  regard  to  the  patient's  physical  con- 
dition. If  in  ordinary  good  health,  Ave  permit  our  patient  to  walk 
with  the  support  of  a  chair,  resting  on  the  back  and  pushing  it 
before  them ;  children,  at  the  expiration  of  two  or  three  weeks  from 
the  time  the  tendon  has  been  severed,  and  adults  in  four  or  five 
weeks.  We  have  seen  patients  walk  in  less  time  than  one  week 
after  the  operation,  having  only  a  supporting  frame  upon  the  foot, 
and  no  unfavorable  circumstance  to  occur ;  but  this  has  not  been 
our  practice ;  and,  beside,  we  have  been  greatly  favored  in  not  hav- 
ing cases  of  ununited  tendons,  and  this  good  fortune  we  attribute 
solely  to  these  precautionary  measures. 

Having  restored  the  contorted  foot  to  normal  form,  the  case  now 
demands  careful  supervision,  in  having  the  supporting  apparatus 
kept  in  perfect  order,  and  worn  night  and  day  as  long  as  there  is 
apparent  Aveakness  in  the  flexors  of  the  foot,  or  shortening  of  the 
plantar  aponeurosis.  It  must,  however,  be  borne  in  mind  that  the 
patient  is  most  unfavorably  conditioned  Avhen  in  bed  at  night  with- 
out a  support  to  sustain  the  foot  at  right  angles  Avith  the  leg;  the 
Aveight  of  the  bed  clothes  contributes  largely  to  continued  extension 
of  the  foot,  as  Ave  have  j)reA'iously  stated,  and  thus  impairs  the 
recuperative  tendency  in  the  paralyzed  muscles. 

In  the  treatment  of  talipes  equinus  resulting  from  other  causes 
than  that  of  infantile  paralysis,  greater  circumspection  only  is 
required  as  to  the  resisting  influences  maintained  by  tense  tissues, 
which  tissues  should  be  severed  after  having  carefully  and  eEEect- 
ually  tested  manipulation  and  extension. 


(xENERAL  Remarks  on  the  Treatment  of  Talipes.    85 


TALIPES   EQUIlsTUS   FROM    VARIOUS    CAUSES. 

Cases  resulting  from  spastic  influence  are,  in  many  instances, 
relieved  by  the  simple  severing  of  the  tendo-Achillis,  requiring  only 
to  be  kept  at  rest  during  the  restoration  of  the  severed  tendon. 
The  operation  often  results  in  arresting  the  involuntary  movements 
of  the  feet  and  legs.  We  have  witnessed  the  most  salutary  results 
from  this  treabnent,  and  do  not  hesitate  to  sever  the  tendon  in  such 
cases,  and  but  seldom  know  of  a  failure  to  improve  the  condition 
of  the  patient,  in  enabling  them  to  place  the  entire  sole  of  the  foot 
to  the  floor.  This  ability  being  accomplished,  tends  greatly  to  their 
improvement  in  walking,  thus  relieving  them  from  a  most  dependent 
condition. 

Talipes  equinus,  when  the  result  of  scrofulous  ulceration  about 
the  joints,  is  entitled  to  the  most  serious  consideration,  as  the 
severing  the  tendons  does  not  always  fulfill  expectations ;  but  the 
further  treatment  is  not  to  be  abandoned  because  of  this  —  manipu- 
lation, as  carefully  and  perseveringiy  practiced,  with  efforts  at  exten- 
sion, will,  in  many  cases,  afford  relief  even  to  the  degree  of  freeing 
the  patient  from' apparent  anchylosis. 

Many  cases  of  talipes  equinus  resulting  from  unfavorable  position 
are,  in  their  incipient  stages,  relieved  by  the  extension  support.. 
This  should  be  tried  first,  and  if  not  successful  in  due  time,  or  if 
the  patient  suffers  from  the  pressure,  the  tendons  should  be  severed 
to  facilitate  the  cure.  Traumatic  cases  having  resulted  in  great 
shortening  of  the  plantar  aponeurosis,  may  not  require  the  severing 
of  the  tendo-Achillis,  but  that  of  the  aponeurosis,  which  will  be 
sufficient  to  accomplish  the  cure,  even  when  great  deformity  exists ; 
requiring,  however,  in  all  cases,  careful  perseverance  in  manipula- 
tion and  use  of  appliances  so  constructed  as  to  yield  to  the  pressure 
of  the  step  of  the  patient,  the  anterior  portion  of  the  foot  being 
kept  constantly  in  a  state  of  extension  by  elastic  force.  This  is 
most  readily  accomplished  by  an  elastic  steel  plate  so  designed 
as  to  be  worn  in  the  shoe,  and,  when  neatly  constructed,  presents 
no  external  appearance  objectionable  to  the  patient —  a  point  gained 
of  valuable  consideration,  because  of  the  appliance  being  worn  more 
constantly  and  to  his  more  immediate  relief. 


86 


Orthop^dia. 


Fig.  46. 


TALIPES   CALCAifEUS. 

Congenital  and  non-congenital  talipes  calcaneus  differ  very  mate- 
rially in  appearance  and  condition.  In  the  former  the  dorsum  of 
the  foot  is  brought  very  nearly  in  contact  with  the  leg,  and  is  held 
rigidly  in  this  position,  the  tuberosity  of  the  os  calcis  presenting  the 
only  point  of  bearing  on  the  plantar  surface.  As  there  Fig.  45. 
is  no  contraction  of  the  plantar  fascia,  the  anterior  por- 
tion of  the  foot  is  simply  elevated,  the  bones  maintain- 
ing their  normal  relation,  with  an  excessive  elongation 
of  the  extensor  muscles. 

Figure  45  shows  a  depression  of  the  heel  and  eleva- 
tion of  the  anterior  portion  of  the  foot  flexed  upon  the 
leg. 

The  non-congenital  condition  of  this  contortion  of 
the  foot  presents  a  depression  of  the  heel   and  slight 
contraction   of  the  plantar   fascia,  which   retains    the 
anterior  portion  of  the  foot  in  a  horizontal  position,  the  os  calcis,  in 
severe  cases,  being  almost  perpendicular. 

The  patient  being  thus  conditioned,  walks 
as  though  on  stilts  (see  figure  46),  the  ante- 
rior extremity  of  the  foot  projecting  hori- 
zontally, and  elevated  some  distance  above 
the  abnormal  base  of  the  heel. 

This  condition  of  the  foot  does  not  remain. 
The  plantar  fascia  continues  to  shorten, 
doubling  the  foot  upon  its  plantar  face 
until  it  assumes  the  appearance  and  condi- 
tion of  a  Chinese  lady's  foot  previously 
represented,  and  if  compressed  in  iron 
shoes  could  have  been  reduced  to  that 
condition. 

Figure  47  shows  the  anterior  portion  of  the  foot  depressed,  and  a 
sharp  doubling  upon  the  os  calcis.  When  in  this  condition,  the 
patient  is  seriously  impaired  in  ability  to  walk,  stumping  as  it  were 
with  a  wooden  leg,  and  readily  fatigued  from  the  slightest  effort  to 
use  their  feet,  and  if  long  continued  from  actual  necessity,  painful 
inflammation  in  the  salient  position  of  the  os  calcis  and  extremities 
of  the  metatarsal  bones,  after  restraining  the  patient  from  walking 
for  several  weeks  at  a  time,  is  not  an  unfrequent  occurrence,  a  most 


General  Remarks  on  the  Treatment  of  Talipes.    87 


serious    embarassment    to  the  indigent,  often  subjecting  them  to 
compulsory  pauperism,  successful   treatment  not  being  attainable 
Fig.  47.  through    elemosynary   institutions,   and    the 

want  of  means  to  purchase  expensive  appa- 
ratus. Happily  they  are  now  furnished  (and 
have  been  for  the  past  twenty  years)  by  the 
Hospital  for  the  Eelief  of  the  Euptured  and 
Crippled,  in  the  city  of  ISTew  York,  being  the 
first  institution  in  the  country  which  gratui- 
tously supplied  orthopsedic  appliances  and  kept 
them  in  repair,  besides  securing  experienced 
and  skilful  surgical  treatment,  as  long  as  may 
be  required  by  either  indoor  or  outdoor 
patients,  over  five  thousand  cases  having  been 
treated  in  the  short  period  of  twelve  months. 


CAUSE    OF  TALIPES    CALCANEUS. 

The  cause  of  congenital  talipes  calcaneus  is  one  of  the  mooted 
subjects ;  however,  some  of  the  supporters  of  the  dynamic  theory, 
as  Mr.  William  Adams  and  Mr.  Lonsdale,  admit  that  probably  it  is 
the  result  of  malposition  of  the  foetus,  and  pressure  in  utero.  Mr 
Lonsdale  observes  :  "  I  have  seen  four  cases  of  congenital  calcaneus 
where  it  could  be  distinctly  traced  to  position  in  utero,  they  being 
breech  presentations,  with  the  legs  extended  upward,  the  feet  being 
doubled  upward  and  pressed  against  the  tibia  in  front."* 

Mr.Tamplin  qbserves  :  "I  have  never  yet  met  with  congeniial  tali- 
pes equinus."  As  before  stated,  congenital  calcaneus  differs  in  the 
simplicity  of  the  contortion,  and  the  prognosis  is  proportionately 
favorable. 


TKEATMENT   OF   CONGElflTAL   TALIPES   CALCANEUS. 

The  cases  that  require  the  severing  of  tendons  are  exceptional, 
and  when  such  cases  do  present,  the  tendons  for  division  are  those 
of  the  tibialis  anticus,  extensor  proprius  pollicis,  extensor  longus 


*  Lancet,  Sept.  1.  1855. 


88 


Orthop^'ebia. 


digitornm,  and  peroneus  tertius.  The  apparatus  for  redressing  the 
contortion  is  represented  in  Fig.  48.  A  sole  plate,  and  cup  for  the 
reception  of  the  heel ;  a  single  upright,  elastic  Fig.  48. 

spring  to  pass  up  the  back  of  the  leg  to  an  en- 
circling band  for  the  leg;  an  adjustable  cup 
for  the  dorsum  of  the  foot,  having  leather  straps 
to  fasten  on  the  heel  cup,  and  tapes  passing 
down  through  slits  in  the  sole-plate  to  be  tied 
underneath. 

With  this  simple  apparatus  which  we  devised 
some  twenty  years  ago,  we  have,  in  most  cases, 
reduced  the  foot  to  normal  form  in  a  few  weeks 
in  cases  not  produced  by  paralysis ;  but  in 
order  to  effect  a  permanent  cure  we  have  ad- 
vised the  continued  application  of  the  apparatus  for  five  or  six  months. 

We  advise,  at  the  outset  of  the  treatment,  gentle  force  to  be  made 
by  the  tapes ;  the  brace  to  be  removed  twice  a  day  and  the  foot 
examined  and  manipulated  with  the  hand.  If  tender  points  pre- 
sent, protect  them  with  lint.  This  formula  is  to  be  continued  for 
a  month  or  more  after  the  foot  is  reduced  to  the  sole-plate. 


TREATMENT   OF   XON-CONGENITAL   TALIPES   CALCANEUS. 

Non-congenital  talipes  calcaneus  presents  a  most  complicated 
anatomical  condition  for  treatment.  In  more  than  a  majority  of 
cases  of  this  contortion,  it  is  the  sequel  of  paralysis  of  the  extensor 
muscles  of  the  leg.     The  anterior  portion  ^ig.  49. 

of  the  foot  is  usually  slightly  everted  in  its 
flexed  condition,  being  elevated  above  the 
dependent  heel  and  nearly  at  right  angles 
with  the  leg.  To  meet  these  indications 
with  suitable  therapeutic  means  has  greatly 
taxed  the  orthopgedist's  ingenuity. 

In  this  stage  of  the  ailment,  tenotomy  is 
but  seldom  required  as  a  preparatory  step  in 
the  treatment.  Extension  apparatus  [Fig. 
49]  miist  be  relied  on,  so  constructed  as  to 
support  the  os  calcis  and  metatarso-phalan- 
geal  point  of  bearing  when  brought  down  to 


General  Remarks  on  the  Treatment  of  Talipes.    89 

the  plantar  plate ;  the  plate  being  held  by  means  of  a  limited  joint 
at  right  angles  with  the  upright  bars  that  pass  perpendicularly  up 
the  leg,  and  secured  by  an  encircling  band.  A  broad  strap  passes 
from  bar  to  bar  about  an  inch  above  the  instep,  intended  to  restore 
the  tibio-tarsal  relation;  pressure  being  made  upon  the  dorsum  of 
the  foot  by  means  of  a  roller. 

The  pressure  upon  the  instep  by  means  of  the  roller,  and  the 
tibial  supporter  in  a  fixed  position  tends  to  a  restoration  of  the  os 
calcis  to  a  normal  position,  which  is  the  principal  indication  to  be 
met. 

This  apparatus,  originally  intended  for  the  redressing  of  non-con- 
genital talipes  calcaneus,  we  devised  some  twenty  years  since,  and 
in  no  instance  have  we  found  it  necessary  to  modify  or  alter  the 
original  construction,  other  than  to  omit  the  use  of  the  tibial  band  — 
which  in  most  cases  is  not  required. 

In  nearly  all  cases  of  non-congenital  calcaneus,  because  of  the 
partial  paralysis  of  the  extensor  muscles,  the  apparatus  must  be 
worn  for  two  or  more  years ;  subjecting  the  patient,  however,  to  but 
comparatively  little  inconvenience — a  laced  boot  being  worn  over 
the  apparatus.  But,  in  this,  as  in  all  other  cases  of  contortion  of 
the  feet,  the  appliances  must  be  ivorji  during  the  niglit.  The  metal 
shoe  should  in  all  cases  be  worn  independent  of  the  ordinary  shoe  ; 
as  the  foot  can  be  much  more  readily  controlled,  and  the  expense  of 
a  night  shoe  saved. 

In  all  the  various  forms  of  talipes  valgus  much  distress  is  often 
induced,  even  to  excoriation  from  the  base  of  supports  applied  to 
the  malleolus  internus,  for  the  relief  of  which  I  have  recently  de- 
vised an  appliance,  quite  simple  in  construction  and  most  effectual 
in  affording  comparative  comfort  and  ample  support,  tending  to  the 
correction  of  the  deformity. 

This  apparatus  is  represented  in  the  following  engraving  (Fig.  50). 

It  consists  of  a  single  upright  bar  of  tolerably  strong  steel,  attached 
by  a  joint  having  a  cushioned  protection  for  the  outer  ankle,  the 
bar  pressing  about  two-thirds  up  the  length  of  the  leg  below  the 
knee,  and  attached  to  a  belt  of  steel,  an  inch  or  more  wide,  encir- 
cling about  two-thirds  of  the  leg,  covered  with  soft  material,  and 
provided  with  a  strap  which  is  continued  around  the  leg,  being- 
fastened  by  a  buckle  or  to  a  stud. 

The  shoe  attachment  of  the  joint  consists  of  a  portion  of  sheet 
steel  passing  down  and  across  the  steel  sole  plate,  and  rises  about 
two  inches  or  less  to  avoid  pressing  the  inner  malleolus.     To  this  is 


90 


Obthop^dia. 


riveted  a  strong  piece  of  leather,  upon  wbicli  is  attached  a  soft 
cushion  with  three  strong  leather  straps,  one  to  pass  over  the  instep, 
one  to  pass  obliquely  up  posteriorly  and  fastened  to  a  stud  placed 
about  one-half  the  distance  up  the  upright  bar,  and  one  anteriorly 
fastened  to  a  stud  on  the  bar  about  one  inch  above  that  for  the 
second  strap. 

The  steel  sole-plate,  which  is  made  just  the  length  of  the  foot,  is 
covered  with  leather  and  the  apparatus  is  complete. 

On  applying  the  shoe  to  the  deformed  foot,  the  instep  strap  should 
be  firmly  drawn  over  and  attached  to  the  stud  below  the  joint.  Next 
the  strap  back  of  the  leg,  elevating  as  much  as  possible  the  mal- 
leolus internus,  is  to  be  fastened,  and  then  the  anterior  strap,  with 
equal  force,  is  attached  to  the  highest  stud  on  the  bar. 

By  this  means  the  foot  will  be  much  improved  in  form,  and  the 
elevating  force  be  borne  with  comjDarative  comfort.  The  apparatus 
can  be  worn  inside  an  ordinary  shoe,  laced  over  the  foot  and  ankle. 
The  brace  should  be  worn  night  and  day  to  insure  a  cure. 

As  we  have  valgus  resulting  from  a  paresis  of  the  muscles  that 
extend  or  flex  the  foot,  the  joint  can  be  limited  to  a  right  angle  or 
to  a  medium  degree,  as  in  that  of  similar  apparatus  described  in 
the  first  part  of  this  book  in  the  chapter  on  talipes  valgus.  Fig.  51 
represents  the  brace  as  applied. 


Fig.  50. 


Fig.  51. 


CHAPTER  IV. 

INFANTILE    PARALYSIS. 

Contortions  the  sequence  of  infantile  paralysis. —  Illustrative  cases. —  Para- 
lysed limbs  susceptible  to  a  restoration  of  power. —  Proper  and  careful  treat- 
ment essential. —  Views  of  Ancients  as  to  infantile  paralysis. —  Galen  on  palsy. 
• — Pott,  Baillie  and  Abercrombie  on  paraplegia. —  Infantile  paralysis  arising 
from  irritation  of  the  primse  vise. —  Prognosis  in  infantile  paralysis. —  Special 
training  in  the  department  of  surgical  science  necessary  to  the  successful 
treatment  of  the  disease. —  The  sequence  of  unrelieved  paralysis. —  The  Lon- 
don ■'  Lancet"  on  origin  and  treatment  of  infantile  paralysis. —  Our  treatment 
of  infantile  paralysis.  —  Exposure  of  infant  to  cold  or  damp,  chief  cause. — 
Congestion  of  the  peripheral  vessels  most  commonly  present. —  Vesication  of 
the  spine,  and  irritants  applied  to  the  ankles  and  wrists  generally  successful  in 
restoring  the  impaired  functions. —  In  advanced  cases  an  asthenic  condition  of 
the  implicated  portion  of  the  spinal  cord  has  ensued. —  Mechanical  and  physi- 
ological treatment  of  infantile  paralysis. —  Patients  usually  in  enjoyment  of 
good  bodily  health. —  Congested  appearance  of  cuticle. —  Atrophied  condition 
of  the  wasted  limb. —  Essential  paralysis. —  Laborde's  definition  thereof. — 
Degeneration  of  the  muscles. —  Extraordinary  cure  of  restoration  of  muscular 
power  in  a  patient  fifty-four  years  of  age,  suffering  from  equiuo-varus  of  both 
feet. —  Another  case  of  a  lady  thirty-nine  years  old. —  Prognosis  for  treatment. 
—  Speciai,  Treatment  op  Contortiok,  the  Sequence  of  Infantile  Par- 
alysis.—  If  unequal  tension  of  muscles  observable,  use  of  electricity  inadmis- 
sible.—  Method  of  obviating  tendency  to  talipes  calcaneus. —  Cases  demanding 
Tenotomy. —  Mr.  Wm.  Adams'  opinion  as  to  severance  of  tendons  in  cases  of 
infantile  paralysis. —  Method  of  treatment  initiated  by  Richard  Barwell. — 
Preference  of  author  for  severance  of  contracted  tendons  as  a  remedy  in  this 
class  of  ailments. — Personal  efforts  in  primary  treatment. —  Electricity  a  pow- 
erful remedial  agent. —  Objection  to  the  Swedish  movement. —  Recovery  fre- 
quently ensues  where  no  system  of  treatment  has  been  attempted. —  Paraly- 
sis the  result  of  caries  of  the  last  cervical  and  first  dorsal  vertebrae. —  Paralysis 
the  result  of  adventurous  treatment. —  Case  in  illustration. —  Posterior 
Genu  Flexum. —  Leading  features  of  this  deformity. —  In  childhood,  nearly 
every  case  curable,  while  neglect  gradually  transforms  it  into  a  permanent 
deformity. —  Treatment  of  infantile  patients. —  Supporting  apparatus. —  Sup- 
port to  be  continued  until  muscular  power  is  restored. —  Time  required  for 
cure  of  deformity. —  Electricity  and  manipulation,  when  skilfully  applied, 
valuable  auxiliaries. —  Contraction  of  iliacus  and  psoas  magnus  muscles. — 
Influence  of  Occupation  Tending  to  Paralysis. —  Writers  and  Painters 
specially  subject  to  paralysis  of  the  hand  and  wrist. —  Frequently  met  Avith 


92  OrtroPuEdia. 

among  slioe-makers,  glass-cutters,  seamstresses  and  compositors. —  Paralytic 
premonitions. —  Drop-wrist.  —  Treatment. —  Apparatus. —  Static  electricity. — 
Effect  on  the  patient,  and  results  in  ameliorating  his  condition. 


COXTORTIOXS    THE    SEQTJEXCE    OF   IXFAXTILE    PAEALTSIS. 

The  ancient  and  some  modern  writers  have  considered  infantile 
paralysis  as  the  sequence  of  apoplexy.  Stall  and  Portal  mention, 
under  the  caption  of  "  Apoplexia  Infantum,"  *  what  they  consider 
to  be  the  most  probable  causes,  such  as  being  subject  to  worms, 
dentition,  and  the  improper  administration  of  opiates. 

M.  Portal  states :  "  I  have  seen  children  of  a  plethoric  constitu- 
tion afflicted  during  dentition  with  a  true  coma  ending  in  palsy  of 
the  arms  or  legs."  We  have  treated  children  laboring  under  coma 
and  stertorous  breathing,  that,  when  relieved  of  the  latter,  the 
sequence  hemiplegia,  and  others  that  resulted  in  paraplegia.  The 
citation  of  a  case  or  two  will  render  the  subject  more  comprehensi- 
ble: One,  the  patient  a  little  girl  four  years  of  age,  of  vigorous 
growth  and  rotundity  of  form,  labored  under  coma  and  stertorous 
breathing.  The  eye  balls  were  so  contorted  laterally  that  only  about 
one-third  of  the  dilated  pupil  could  be  seen.  An  emetic  was  admin- 
istered, when  a  quantity  of  undigested  pith  of  cabbage-stalk  was 
ejected  and  the  child  restored  at  once  to  consciousness  and,  within 
an  hour,  to  the  ability  of  articulating.  Paralysis  of  the  right  arm 
and  leg  was  the  sequence. 

The  other,  a  little  girl  three  years  of  age,  equally  well  developed, 
and  giving  a  history  of  previous  good  health,  labored  under  coma 
and  stertorous  breathing  with  constant  agitation  of  the  right  side, 
and  eyeballs  divergent.  An  emetic  was  given,  and  failed  to  act  for 
fifteen  mmutes.  The  patient  was  then  placed  in  a  tepid  bath  and 
ice  applied  to  the  head.  After  a  few  minutes  there  Avas  ejected  a 
quantitv  of  unripe  gooseberries.  The  sequence  in  this  case,  para- 
plegia. These  children,  being  carefully  treated,  recovered  from 
their  paralytic  condition  in  about  eighteen  months.  Of  younger 
children  laboring  under  coma,  stertorous  breathing,  and  convulsions 
during  dentition,  we  have  treated  many  cases ;  and  the  result  has 
been  in  nearly  every  instance  partial  paralysis  of  the  limbs. 

*  1  Portal,  p.  63. 


Infantile  Paralysis.  9E 

Another  not  uncommon  cause  of  infantile  paralysis  is  exposure 
from  sitting  or  lying  on  cold,  damp  ground.  Cases  have  been  pre- 
;sented  by  intelligent  parents  where  the  mothers  had  been  compelled 
to  leave  their  babes  with  the  elder  children,  who  placed  them  upon 
the  grass  or  damp  ground  while  they  engaged  in  play.  From  this 
exposure  ensued  the  paralysis  in  one  or  more  limbs.  This  is  so 
common  an  occurrence  that  a  reasonable  doubt  cannot  be  enter- 
tained as  to  its  being  a  cause  of  infantile  paralysis. 

Many  cases  occur  that  are  represented  as  the  sequence  of  measles, 
scarlet  fever  and  cholera  infantum,  and  others,  in  which  no  reason- 
able cause  for  the  paralytic  condition  can  be  given.  The  mothers 
or  nurse's  statement  is,  that  the  child  previously  enjoyed  good 
health,  when,  on  a  stated  evening,  it  had  a  slight  fever,  was  rather 
restless  during  the  night,  and  on  the  following  morning  was  found 
to  have  one  or  more  limbs  paralyzed.  In  some  cases,  in  a  month 
or  two,  the  arm  has  been  quite  relieved,  the  leg  remaining  powerless, 
or  but  slightly  improved,  with  a  tendency  to  contortion.  In  others, 
the  arm  remained  powerless  at  the  shoulder  whilst  the  leg  had  recov- 
ered. Thus,  it  will  be  observed,  that  the  limbs  are  variously  affected, 
and  in  nearly  all  cases  susceptible  to  a  restoration  of  power. 

The  tendency,  in  these  cases  of  infantile  paralysis,  is  to  contor- 
tion of  the  limbs  affected,  if  not  properly  supported  in  normal 
form,  and  this  contortion  is  the  result  of  the  recuperative  tendency 
of  some  muscles,  or  the  shortening  of  those  least  impaired.  Mr. 
Wm.  Adams  states:  "I  believe  all  these  deformities  may  be  pre- 
vented by  judicious  treatment;  in  fact,  that  there  never  need  be 
another  example  of  deformity  in  these  cases  if  the  liability  to  their 
occurrence  and  the  mode  of  their  production  were  generally  under- 
stood." 

A  careful  diagnosis  is  greatly  to  the  advantage  of  the  patient, 
but  practical  information  on  the  treatment  is  as  essential  to  their 
relief,  tending  to  the  proper  construction  of  appliances,  and  their 
modification  as  relief  progresses.  The  normal  increasing  ability  of 
motion  in  the  muscles  must  be  carefully  considered,  and  the  first 
required  support  diminished  in  ratio  to  the  improvement,  or  a 
serious  impediment  to  progress  in  strength  of  muscles  will  result 
from  limiting  the  necessity  for  vital  energy  by  continued  support. 

The  ancients  were  evidently  familiar  Avith  some  of  the  now  well 
known  causes  of  paralysis  in  children,  but  they  make  no  especial 
mention  of  the  various  inimical  influences  tending  to  a  peculiar 


94  Orteop^dia. 

condition,  as  in  that  of  paralytic  seizures  in  infants.  Galen  makes 
the  following  remarks  upon  palsies  : 

"  If  a  nerve  becomes  thickened  and  harder  than  natural,  the 
propagation  of  its  power  is  hindered;  or  if  it  be  compressed  by 
some  hard  body,  it  cannot  afford  a  free  passage  to  the  power.  If 
compression  be  made  on  nerves  by  cords  or  by  the  hand,  by  phleg- 
monous or  schirrous  tumors  of  neighboring  parts,  or  by  luxated  or 
fractured  bones,  the  nerves  become  first  torpid,  and  afterwards 
entirely  lose  sense  and  motion."* 

Cold,  he  states,  often  injures  a  single  muscle,  especially  that  sit- 
uated upon  the  superficies  of  the  seat,  as  when  a  person  sits  upon  a 
cold  stone,  or  remains  too  long  in  the  cold.  (This  applies  equally 
to  children  that  are  paralyzed  from  sitting  on  cold,  damp  ground.) 
Forestus  treats  of  palsy  in  the  hands  from  cold  and  moisture  applied 
to  the  neck,  and  of  palsy  of  the  bladder  from  a  similar  application 
to  the  back.f 

Mr.  Pott  states  that  a  great  proportion  of  cases  of  paraplegia, 
especially  in  infants,  depends  upon  constitutional  affection  of  the 
spine.J  And  he  further  states  that  adults  are  by  no  means  exempt 
from  caries  of  the  spine  terminating  in  paraplegia,  but  that  he 
never  saw  a  case  of  it  at  an  age  beyond  forty. 

Drs.  Baillie  and  Abercrombie  attribute  all  cases  of  paraplegia  to 
lesions  of  the  brain,  and  claim  that  children  are  subject  to  the 
affection.  § 

Mr.  Charles  Bell  appears  to  be  the  first  to  invite  attention  to 
paralysis  in  children  arising  from  irritation  of  the  primge  vise.  H'3' 
states  that  there  is  a  class  of  local  palsies  which  are  neither  pre- 
ceded by  pain,  inflammation,  nor  disorder  of  the  brain,  but  arise 
from  irritation  of  the  bowels,  and  that  the  loss  of  motion  from  this- 
cause  occurs  often  in  children,  "  and  that  among  those  wretched 
Irishwomen  who  apply  as  out-patients  to  our  hospital,  and  with  a 
child  at  the  breast  with  its  arm  hanging  down,  entirely  without 
muscular  power.  In  such  cases  I  have  invariably  found,  on  ques- 
tioning the  mother,  that  there  has  been  disorder  in  the  bowels,  with 
a  passing  of  green  stools,  griping  and  spasms  previous  to  the  par- 
alytic seizure  of  the  limb." 

*  "  Galen  de  locis  affectus,"  lib.  4. 

f  Forestus,  obs.,  p.  34. 

X  Pott,  p.  20. 

§  Abercrombie  on  Diseases  of  the  Brain,  p.  33. 


Infantile  Paralysis.  95 

This  is  a  true  representation  of  many  cases  thus  conditioned,  and 
presented  for  treatment,  except  tJiat  children  having  green  stools 
and  spasms,  have  pain.  Yet  this  cause  afflicts  but  a  very  limited 
number  with  infantile  paralysis,  compared  with  that  of  the  several 
causes  previously  stated,  and  paralysis  the  sequence  of  inimical 
impressions  made  upon  the  digestive  organs  and  reflected  upon  the 
nervous  centre,  tending  to  a  partial  arrest  of  nervous  influence,  and 
limited  to  the  impairment  of  only  certain  classes  of  muscles,  and 
in  some  instances  to  that  of  a  single  muscle,  or  the  flexor  muscles 
of  one  limb  and  the  extensor  of  its  fellow,  both  limbs  being  thus  so 
affected  as  to  incapacitate  the  child  to  stand  alone.  Upon  examina- 
tion, however,  certain  muscles  will  be  found  to  be  in  active  condi- 
tion, tending  to  shorten,  the  equilibrium  of  normal  antagonizing 
force  being  interrupted.  Contortion  is  the  inevitable  sequence 
under  such  circumstances,  if  not  arrested  by  the  aid  of  acquired 
knowledge  in  the  treatment  of  such  cases. 


PROGN^OSIS  IN"  IISTFANTILE  PARALYSIS, 

The  recuperative  tendency  in  all  cases  of  infantile  paralysis  exists 
largely,  and,  in  many  instances,  even  without  skilled  interference, 
the  normal  status  is  recovered.  Inexperienced  practitioners,  how- 
ever, are  liable  to  place  too  much  dependence  upon  this  tendency, 
and  to  defer  the  simple  treatment  until  the  more  complicated  is 
required  ;  and  then,  to  obtain  a  suitable  therapeutic  agent,  depend 
upon  the  instrument-maker's  judgment.  This  sad  practice  is  daily 
resorted  to,  even  by  those  who  make  themselves  proficient  in  the 
treatment  of  this  class  of  ailments.  Anxious  parents,  prompted  by 
the  love  they  bear  for  their  afflicted  children,  make  repeated  efforts 
for  relief,  bewailing  their  mental  sufferings,  and  expenditures  they 
can  but  ill  afford,  having  availed  themselves  of  the  services  of  those 
Avho  are  reputed  to  be  the  most  eminent  in  the  medical  profession, 
and  all  without  obtaining  an  arrest  of  the  increasing  contortion. 
Cases  thus  deplorably  conditioned  have  been  cured  —  patients  that 
have  suffered  from  eighteen  months  to  twenty  years  of  age. 

The  practical  attainment  of  knowledge  in  this  department  of 
surgical  science  determines  a  favorable  prognosis  in  nearly  all  cases 
of  infantile  paralysis,  the  ailment  having  now  been  brought  within 
the  rational  influence  of  pathological  and  therapeutical  science,  and 


96  Orthop^dia. 

requiring  only  assiduity  from  the  skilled  practitioner,  together  with 
invariable  obedience  from  patients  and  attendants,  to  ensure  relief 
in  nearly  every  case  of  infantile  paralysis. 


THE    SEQUENCE    OF    UXRELIEVEU    PARALYSIS. 

The  result  of  inefficient  or  no  treatment  tends  to  atrophy  and 
persistent  contortion  of  the  limb  or  limbs,  which  are  much  influ- 
enced by  continued  unfavorable  position,  as  in  the  instance  of 
permitting  a  child  to  daily  remain  in  a  sitting  posture  in  a  small 
chair,  which  is  made  an  available  means  of  locomotion  by  muscular 
effort  of  the  arms  and  body.  In  this  dependent  condition  many 
children  are  allowed  to  remain  for  life,  because  of  the  opinion  of 
the  family  practitioners  in  medicine  that  such  cases  are  incurable, 
and  only  because  of  their  inability  to  relieve  the  patient,  which,  as 
must  be  admitted,  is  almost  an  impossibility  for  the  general  practi- 
tioner. Clinical  instruction  in  this  class  of  ailments  is  most 
difficult  to  obtain,  and  suitable  apparatus  to  meet  the  various 
indications  that  present,  impossible  without  experienced  knowledge 
to  devise  the  therapeutic  agent  to  be  constructed  by  the  skilled 
mechanician. 

As  this  work  is  only  intended  as  a  practical  treatise  on  the  seve- 
ral ailments  included  therein,  we  refer  the  reader  for  more  general 
information  to  the  most  excellent  work  of  Mr.  Wm.  Adams  on 
Club-foot,  and  the  invaluable  works  of  Heine  :  "  Practical  Treatise 
on  the  Diseases  of  Children,"  translated  by  P.  H.  Bird,  London, 
1854;  West,  "Lectures  on  the  Diseases  of  Infancy  and  Childhood," 
3d  edition,  London,  1854,  and  many  more  recent  Avorks  of  merit  on 
the  subject  at  home  and  abroad  too  numerous  to  mention,  but  of 
great  value  in  affording  practical  information  upon  the  subject. 

The  impression  made  upon  the  nerve  centres  have  not,  as  yet, 
been  satisfactorily  determined  —  subject-matter  tending  to  careful 
and  satisfactory  examination  not  having  been  afforded,  because  of 
limited  opportunity.  Barthez,  Eiellet,  Dr.  Fliess,  Mr.  Wm.  Adams, 
and  recently  Dr.  J.  Kussell  Keynolds,  physician  to  the  University 
College,  London,  have  each  and  all  come  to  the  conclusion  that  the 
brain  is  but  seldom,  if  ever,  implicated  in  the  primary  impression 
that  results  in  infantile  paralysis.     The  latter  authority  states,  in 


Infantile  Paral  ysis.  9  7 

a  letter  published  in  the  London  "  Lancet "  of  July,  1868,  p.  35, 
the  following  : 

"The  muscles  and  bones  are  small,  and  the. former  often  lose  all 
of  their  characteristic  structure  ;  and  until  recently  it  has  been 
affirmed  that  beyond  these  changes  of  the  limbs  nothing  abnormal 
was  to  be  found.  You  may  read  descriptions  of  post  mortem 
examinations  in  which  it  is  stated  that  the  brain,  spinal  cord  and 
nerves  were  found  to  be  in  their  natural  state  ;  and  it  is  only  of  late 
that  by  a  process  of  more  minute  investigation,  the  real  malady 
has  been  discovered.  M.  Laborde  has  shown  that  there  is  a  distinct 
change  in  certain  portions  of  the  spinal  cord ;  that  the  interior 
columns  are  more  translucent  than  natural,  and  present  a  very 
appreciable  greyish  rose  tint  to  the  naked  eye,  and  that  a  similar 
change  may  be  observed,  though  to  a  less  degree,  in  the  lateral 
columns.  The  consistence  of  these  tracts  of  nerve  tissue  is  dimin- 
ished; and  upon  microscopic  examination  there  may  be  observed  a 
marked  proliferation  of  the  elements  of  the  connective  tissues, 
cells  and  nuclei  being  dispersed  in  the  midst  of  a  finely  granulated 
substance  in  which  there  are  fibrils  of  extreme  tenuity.  In  the 
parts  which  are  most  affected,  tubules  are  either  lost  altogether  or 
they  present  a  varicose  appearance,  while  the  other  portions  of  the 
spinal  column  preserve  a  perfect  integrity." 

In  the  statements  of  this  authority  we  feel  disposed  to  jalace 
much  reliance,  it  having  been  sustained  by  practical  results. 

It  has  been  our  practice  for  many  years,  when  applied  to  for 
treatment  in  the  early  stage  of  seizure  of  infantile  paralysis  to  ques- 
tion the  attendants  as  to  the  condition  of  the  child  at  the  time  of 
the  attack,  or  immediately  preceding  it,  and  if  informed  that  the 
child  was  feverish  or  restless  on  the  day  or  night  previous  —  that 
being  the  only  symptom  of  impairment  of  health  —  we  endeavor  to 
ascertain,  by  examination  of  the  mouth,  the  condition  of  the  gums; 
and,  if  no  irritation  is  found  there,  inquire  into  the  diet  and  condi- 
tion of  the  bowels,  or  as  to  what  exposure  the  little  patient  has  been 
subjected ;  sitting  on  cold,  stone-pavement,  damp  ground,  Avet  floor 
or  in  excessive  drafts  of  air.  These  are  the  most  common  causes  of 
the  slight  fever  that  tends  to  infantile  paralysis ;  and  the  treatment 
required  is,  with  some  regard  to  the  exciting  cause ;  at  the  same 
time  applying  rubefacients  to  the  extremity  of  the  paralyzed  limb, 
and  wet  cloths  at  a  temperature  of  about  40°  Fahr.  to  the  spine ;  to 
be  continued  for  forty-eight  hours,  if  relief  is  not  sooner  obtained. 


98  Orthop^bia. 

This  method  has  relieved  patients  in  less  time  than  twenty-four 
hours,  and  without  the  least  tendency  to  relapse. 

The  patient,  not  being  relieved  by  judicious,  ordinary  treatment, 
may  be  considered  as  laboring  under  a  very  decided  impression  upon 
some  portion  of  the  cerebro-spinal  centres,  most  commonly  conges- 
tion of  the  peripheral  vessels.  A  similar  condition  is  often  the 
sequence  of  protracted  disease ;  as  that  of  scarlatina,  rubeola,  per- 
tussis, and  cholera  infantum,  and  it  is  the  exception  to  meet  with  a 
case  of  paraplegia  from  any  other  causes,  where  caries  of  the  spine 
is  not  a  concomitant. 

In  every  instance  where  contortion  of  the  muscles  is  not  appa- 
rent in  cases  of  infantile  paralysis,  and  the  seizure  is  of  less  than 
a  month's  duration,  we  vesicate  the  spine  and  obtain  as  large  a  drain 
of  serum  as  possible  by  the  frequent  change  of  emollient  poultices 
and  the  repetition  of  vesication  to  a  reasonable  degree,  and  if  improve- 
ment is  not  apparent,  irritants  are  applied  to  the  ankles  and  wrists 
of  the  paralyzed  limbs,  and  in  this  stage  of  the  ailment  this  treat- 
ment has  been  most  frequently  attended  with  decided  success.  The 
drain  of  serum  relieves  the  congested  condition  of  the  peripheral 
vessels  of  the  spinal  cord,  and  the  irritants  to  the  extremities  tend 
to  the  restoration  of  the  normal  status  of  the  impaired  functions  of 
the  implicated  nerves. 

In  the  more  advanced  cases,  or  those  of  longer  duration,  when 
contortion  has  commenced,  we  then  consider  that  an  asthenic  condi- 
tion of  the  implicated  portion  of  the  spinal  cord  has  ensued,  and 
that  irritant  plasters  constantly  applied  to  the  spinal  column  are 
indicated,  with  that  of  other  therapeutical  agents,  to  restore  and 
maintain  the  normal  form  of  the  contorted  limbs. 

This  stage  of  the  ailment  brings  us  to  a  consideration  of  what  is 
usually  denominated  the  mechanical  and  physiological  treatment  of 
infantile  paralysis,  that  has  resulted  in  contortion,  and  a  degenerate 
condition  of  the  muscles  from  a  partial  arrest  of  nutrition. 

Patients  in  this  advanced  stage  of  the  paralysis  usually  enjoy  good 
bodily  health  and,  as  Dr.  Reynolds  remarks,  it  is  rare  to  find  on 
them  bed-sores  or  other  evidences  of  localized  mal-nutrition  of  the 
skin.  ISTormal  warmth,  however,  is  deficient  and  maintained  with 
much  difficulty  by  artificial  means.  The  want  of  vital  impetus  in 
the  circulation  is  apparent,  from  the  congested  appearance  of  the 
skin  of  the  diseased  limb,  which  not  only  fails  to  maintain  its  mus- 
cular development,  but  in  some  instances  diminishes  in  circumfe- 


Infantile  Paralysis.  99 

rence  rapidly,  yet  it  is  but  rarely  that  the  bones  fail  to  keep  pace 
in  growth  with  those  in  the  corresponding  but  healthy  limb. 

The  loss  of  equilibrium  in  muscular  force  induces  an  inability  to 
control  the  limb,  resulting  in  an  apparent  shortening  of  the  leg  Avheu 
sustaining  the  weight  of  the  body. 

The  sensibility  of  the  paralyzed  limbs  is  usually  found  to  be  in  a 
normal  condition,  or  nearly  so,  when  carefully  tested,  and,  as  here- 
tofore stated,  it  is  only  certain  groups  of  muscles  that  are  paralyzed. 
Thus  it  will  be  observed  in  some  cases  that  an  obvious  wasting  of 
the  gluteal  region  of  the  affected  limb  has  taken  place,  and  no 
decrease  of  rotundity  of  the  thigh,  or  an  atrophied  condition  of  the 
thigh  and  a  tolerable  development  of  the  leg  maintained.  A  simi- 
lar condition  will  be  found  in  the  arm  and  shoulder,  the  mal-nutri- 
tion  being  most  observable  in  the  deltoid  muscle,  supra  and  infra 
spinatus  and  scapula,  whilst  the  pectorales,  major  and  minor,  are 
seemingly  unimpaired ;  or,  all  of  these  muscles  may  be  paralyzed, 
and  the  muscles  of  the  arm  and  hand  active.  Under  this  condition, 
the  head  of  the  humerus  may  be  seen  distinctly,  and  if  the  arm  is 
not  supported  by  sustaining  the  elbow  from  the  opposite  shoulder, 
a  separation  of  two  inches  will  eventually  take  place  in  the  joints, 
rendering  the  restoration  of  the  limb  to  usefulness  impossible. 
Patients  in  this  deplorable  condition  have  applied  for  treatment, 
stating  that  they  had  been  advised  by  their  physician  not  to  have 
the  arm  supported  by  a  sustaining  bandage,  as  it  would  deprive  the 
limb  of  motion  (actually  an  essential  to  the  only  reliable  means  of 
cure).  It  is  true,  exercise  is  essential  to  cure,  but  it  cannot  be  taken 
with  the  arm  in  its  pendent  condition  ;  the  muscles  should  be 
manipulated  about  the  shoulder,  and  the  arm  supported  from  the 
elbow,  and  exercised  as  constantly  as  possible. 

As  this  ailment  appears  to  be  strictly  local,  it  has  been  termed 
"  essential  paralysis,"  and  noted  as  peculiar  to  young  children. 
Laborde,  in  his  treatise  "  De  la  Paralysie  dite  essentielle  de  I'En- 
fance,"  limits  the  susceptible  period  to  from  nine  months  to  four 
years  of  age.  This  we  consider  a  reasonable  limit,  but  there  are 
exceptional  cases,  both  older  and  younger,  presented  to  the  ortho- 
pfBdist  for  treatment,  as  that  of  ordinary  cases  laboring  under  the 
sequence  of  paralytic  seizure,  contortion  most  commonly  of  the 
foot,  with  atrophy  of  the  leg,  a  comparatively  limited  number  hav- 
ing the  muscles  of  the  thigh  impaired  as  well  as  those  of  the  hip, 
the  knee  being  advanced,  bringing  the  leg  to  an  obtuse  angle  with 


100  OrtroPuEdia. 

the  thigh,  while  others  have  the  sustaining  ligaments  of  the  knee 
flaccid,  permitting  it  to  fall  backward.  In  cases  where  both  limbs 
are  affected,  we  usually  have  the  advanced  knee  with  the  foot  pre- 
senting a  case  of  talipes  equinus  or  equino-varus,  and  in  the  other, 
the  knee  inclining  backward,  and  the  foot  presenting  a  case  of  valgus 
or  equino-valgus. 

In  these  cases,  when  of  some  duration,  the  muscles  degenerate 
from  a  normal  condition  of  development  to  that  of  containing 
deposits  of  flat  globules ;  but  the  sarcolemma  areolar  membrane 
and  connective  tissues  maintain  their  integrity  to  an  ability  of  again, 
under  favorable  circumstances,  resuscitating  the  impaired  limbs. 
A  similar  condition  exists  in  the  nerve  tissue,  the  nerve  centre 
being  excited  into  an  approaching  normal  condition,  all  of  which 
has  been  accomplished  by  judicious  treatment  in  patients  whose 
limbs  have  been  extremely  atrophied  and  powerless  for  twelve  or 
more  years.  It  is  true  that  there  are  various  degrees  of  improve- 
ment in  the  paralyzed  limbs,  some  never  being  fully  restored  to  an 
actual  ordinary  fullness  and  strength,  though  of  decided  usefulness 
to  the  patient,  Avhen  so  far  restored  as  to  sustain  a  perpendicular 
bearing  upon  the  limbs  of  the  superincumbent  weight  of  the  body. 
This  approach  to  a  normal  condition  tends  largely  to  the  future 
increase  of  strength  in  the  impaired  muscles  at  almost  any  age, 
which  fact  we  have  before  alluded  to  —  the  statement  of  Mr.  Wni. 
Adams,  that  he  restored  a  gentleman  of  fifty-four  years  of  age,  who 
was  afflicted  with  equino-varus  of  both  feet,  and  compelled  to  use 
crutches  in  attempting  to  walk.  Previous  to  the  treatment  of  Mr. 
Adams  he  had  consulted  Sir  A.  Cooper,  Mr.  Keat,  Sir  B.  Brodie, 
Sir  Charles  Bell,  Magendie,  Dupuytren  and  Frauquier;  and  not 
one  of  these  eminent  surgeons  had  given  him  relief,  because  of  their 
want  of  practical  information  in  regard  to  the  severing  of  tendons 
and  properly  devised  apparatus,  the  only  reliable  means  of  affording 
relief  in  such  cases. 

Another  interesting  case  is  spoken  of  by  Mr.  Adams:  that  of  a 
lady  thirty-nine  years  of  age  who  was  relieved  after  having  labored 
under  contortion  of  the  feet,  the  sequence  of  infantile  paralysis, 
from  the  age  of  five  years  —  being  so  decrepit  at  the  time  of  treat- 
ment as  to  render  it  necessary  for  her  to  be  carried  from  room  to 
room  by  a  servant.  The  severing  of  tendons  restored  to  her  the  use 
of  her  limbs  and  the  ability  to  walk  without  support. 


Infantile  Paral  ysis.  1  o  1 

The  prognosis  for  treatment  are  clearly  defined  in  the  results  of 
the  above  cases ;  the  lady  being  relieved  of  contortion  of  the  feet, 
the  sequence  of  infantile  paralysis,  and  of  thirty-four  years'  duration  ; 
and  the  gentleman  being  cured  at  the  age  of  fifty-four  years. 


SPECIAL    TEEATMENT   OE    CONTORTION'    THE     SEQUENCE    OF   INFAN- 
TILE    PARALYSIS. 

Contortions  of  the  feet  —  the  result  of  infantile  paralysis  in  its 
incipiency  —  may  be  relieved  in  many  instances  by  elastic  support- 
ing force ;  but  what  is  better,  when  opportunity  is  afforded  the 
practitioner,  is  by  sustaining  the  affected  limb  or  limbs,  making 
available,  during  the  early  period,  all  the  therapeutic  means  of 
restoring  energy  in  the  impaired  limb.  For  local  treatment, 
manipulation  and  electricity  in  its  various  forms  should  be  care- 
fully applied  and  varied,  if  one  form  fails,  but  in  its  most  limited 
force,  for  ten  days,  when  it  may  be  increased  moderately  if  improve- 
ment is  manifested,  without  contraction  of  one  or  more  muscles 
tending  to  contortion.  Whenever  an  unequal  tension  of  the  mus- 
cles is  observed  electricity  is  inadmissible,  and  should  be  discon- 
tinued; instead,  suitable  means  should  be  applied  to  sustain  the 
limb  in  normal  form ;  resisting  the  tendency  of  certain  muscles  to 
shorten,  yet  permitting  the  movement  of  the  limb  by  limited  motion, 
that  the  enfeebled  muscles  may  be  exercised. 

If  there  is  a  tendency  of  the  gastrocnemius  to  shorten,  the  form 
of  apparatus  as  shown  in  Fig.  52,  having  a  limited  joint  at  the 
ankle,  must  be  used  to  meet  the  indication.  By  taking  hold  of  the 
sole-plate  at  the  toe  the  foot  can  be  flexed  upon  the  leg,  and  the 
patient  being  unable  to  walk,  passive  exercise  can  be  thus  given  to 
tolerable  advantage.  In  this  condition  of  the  patient,  the  external 
application  of  strychnia  has,  in  our  practice,  answered  an  admirable 
purpose  when  applied  to  the  enfeebled  muscles  daily,  for  some 
months,  carefully  cleansing  the  surface  of  the  skin  with  warm 
water  and  soap  before  each  application  — 

'^  Strychniae  sulphatis,  grs.  xii. 
Adipis  I  i. 

Jkt.      ft.    ung.  ^ 

and,  as  an  adjuvant  in  the  treatment  we  apply  a  narrow  plaster  of 
Burgundy  pitch  to  the  lower  third  of  the  spine,  in  cases  of  paralysis 


102 


Orthop^dia. 


of  the  lower  limbs.  The  patient's  general  health  must  of  course 
be  carefully  considered,  as  they  are  not  always  in  a  favorable  condi- 
tion when  laboring  under  this  local  derangement ;  and  moderate  exer- 
cise, inviting  motion  in  the  impaired  limb  or  limbs,  should  also  be 
made  available. 

In  cases  of  paraplegia,  where  contraction  of  certain  muscles  has 
not  ensued,  or  the  paraplegic  condition  is  not  induced  by  caries  of 
the  last  cervical  and  first  dorsal  vertebrae,  steel  supports  to  the  hips 
and  even  to  the  axillse  are  a  desirable  auxiliary  to  the  restoration  of 
power  to  the  paralyzed  limbs.  The  patient  being  placed  in  an 
erect  position  for  a  reasonable  duration  of  time  soon  desires  further 
privileges,  and  is  apt  to  concentrate  his  will  in  an  effort  at  locomo- 
tion which  contributes  largely  to  the  accumulation  of  strength, 
however  feeble  the  influence  may  be  at  the  first  attempt ;  for  as 
long  as  vitality  exists  in  the  muscles  they  are  susceptible  of  being 
influenced  by  the  will  to  their  improvement,  and,  in  a  large  majority 
Mg.  52.  of  cases  of  infantile  paralysis,  to  perfect  res- 

toration when  assisted  by  skilful!}'  contrived 
mechanical  support.  This  remark  applies 
with  equal  force  to  the  treatment  of  adults. 
The  accompanying  engraving  presents 
the  form  of  apparatus  we  have  applied  to 
paralytic  patients  during  the  past  thirty 
years. 

The  springs  must  extend  from  the  axillae 
to  the  feet  ;  the  feet  supported  by  a  sole- 
plate  and  a  cup  for  the  heel,  and,  in  some 
cases,  a  limited  joint  at  the  ankle,  keeping 
the  foot  at  a  right  angle  with  the  leg.  The 
other  joints  are  so  constructed  as  to  be  per- 
fectly fixed  by  means  of  a  strong  steel  slide 
as  at  A,  intended  to  move  easily  over  the 
end  of  the  bar  extended  beyond  the  axis  of 
the  joint  —  the  joint  being  now  represented 
as  free  to  permit  of  the  patient's  sitting 
down,  while  at  B  the  slide  is  upon  the  extend- 
ed bar,  and  sustains  the  limb  in  the  erect 
position.  A  similar  arrangement  will  be 
observed  at  the  hip.  The  hips  are  encircled  by  a  broad  steel  band 
from  which  ascends  a  bar  to  each  axilla,  and  two  more  to  the  sup- 


Infantile  Paralysis. 


103 


port  of  the  back;  being  comiected  at  proper  Fig.  53. 

distances  by  a  steel  band  that  crosses  the 
back  and  extends  through  each  axilla.  This 
frame  is  maintained  by  some  strong  textile 
fabric  ;  being  laced  in  front  and  kept  extend- 
ed by  whalebones. 

Fig,  53  gives  a  back  view  of  the  apparatus, 
A  is  a  buckle  and  strap  attached  to  a  broad 
webbing  strap  (B),  which  crosses  the  hips 
over  the  joints,  and  when  the  joints  are  locked 
assists  in  supporting  that  portion  of  the  pa- 
tient which  otherwise  would  project  backward. 

Cases  present  for  treatment,  where  there  is 
such  a  relaxed  condition  of  the  muscles  about 
the  hip,  and  extension  of  the  ligamentum 
teres,  that  the  head  of  the  thigh  bone,  if  not 
sustained,  will  escape  from  the  cotyloid  cavity. 
To  sustain  the  normal  relation  of  the  joint, 
the  following  apparatus  has  been  constructed 
by  us,  and  applied  for  the  past  twenty  years, 
with  great  advantage  to  the  patients. 

A  represents  a  piece  of  sheet  steel  attached  to  the  upright 
bar  below  the  thigh  joint,  and  curved  in  the  form  of  a  hook, 
ing  only  the  posterior  portion  of  the 
bone,  so  as  to  sustain  the  head  of  the  os 
femoris  in  the  cotyloid  cavity.  The  at- 
tenuated condition  of  the  integument 
permits  the  bone  to  be  grasped,  and,  by 
means  of  the  belt  about  the  hip,  is  per- 
fectly sustained,  B  represents  a  limited 
joint  at  the  knee  when  there  is  only  an 
impairment  in  the  strength  of  the  sus- 
taining integuments  of  the  knee,  permit- 
ting posterior  flexion,  C  represents  the 
joint  that  may  be  applied  in  case  of 
necessity.  D  simply  shows  that  gait- 
ers can  be  worn  over  the  apparatus 
when  applied  to  the  feet,  which  appa- 
ratus, being  separate  from  the  shoes 
or  gaiters,  is  not  objectionable  in  being 


thigh 
catch- 


Fig.  54, 


104 


Orthop^bia. 


worn  by  the  patient  when  in  bed,  an  essential  necessary  to  ensure 
a  cure. 

In  some  cases  there  presents  an  increasing  tendency  to  elevation 
of  the  instep,  in  both  children  and  adults,  which,  if  not  arrested 
in  time,  tends  to  talipes  calcaneus,  an  actual  elongation  of  the  tendo- 
Achillis.  This  may  be  relieved  by  the  daily  use  of  a  shoe  made 
after  the  following  plan  :  an  elastic  steel  plate  is  curved  upward 
and  fitted  to  the  inside  of  a  shoe,  the  shoe  being  made  to  lace  upon 
the  foot  from  the  toe.  The  plate  is  curved  upward  from  about  the 
anterior  two-thirds  of  the  length  of  the  sole  of  the  shoe,  the 
elevation  at  the  toe  being  about  an  inch  and  a  half.  The  heel 
portion  of  the  spring  plate  is  firmly  rivited  to  the  inside  of  the 
Ftg.  55.  lieel  of  the  shoe,  leaving  the  anterior 

portion  free,  so  that  in  walking  the 
spring  will  necessarily  be  borne  down 
by  the  front  of  the  foot,  and  thus,  from 
resistance,  tend  to  relieve  the  contracted 
tissues. 

By  Fig.  55,  A  points  to  the  spring  plate 

^     ^^'''=— ^         "^  -rra'     within  the  shoe  as  elevated  at  the  toe. 

Well  regulated  elastic  extension  will  relieve  incipient  cases  of 

contraction,  if  carefully  persevered  in ;  but  after  some  duration 

of  this  contracted  condition,  it  is  with  greatly  increased  difficulty 

that  it  is  overcome.  The  suffering 
caused  by  concentrated  pressure  is 
often  unendurable,  and  in  those  con- 
firmed cases  of  contracted  feet  relief 
cannot  be  afforded  by  means  of  the 
best  advised  elastic  force,  but  divis- 
ion of  the  shortened  tissue,  even  to 
ligaments,  is  demanded  as  an  auxiliary 
aid.  By  this  preparatory,  or  additional 
treatment,  nearly  every  patient  laboring 
under  contorted  limbs,  the  sequence  of 
infantile  paralysis,  or  other  causes  affect- 
ing adults,  can  be  greatly  relieved,  and 
many  cases  of  contorted  and  atrophied 
limbs  restored  to  normal  usefulness.  When  the  plantar  fascia 
has  been  divided,  the  apparatus  represented  is  applied.  (See  Fig.  56.) 


Fig. ^6. 


Infantile  Paralysis.  105 

A  steel  sole-plate  and  cup  for  the  heel.     And  when  the  roller  is 
applied  over  the  instep,  a  shoe  can  be  worn  over  the  whole. 


CASES   DEMANDING    TENOTOMY. 

A  persistent  condition  of  the  shortened  muscles  tends  not  only  to 
the  arrest  of  development,  but  finally,  to  degeneration  of  the  mus- 
cular tissue  ;  depriving  it  of  its  contractile  power,  and  thus  arresting 
motion  in  the  joints,  and  inducing  and  maintaining  the  contorted 
position.  Not  only  does  it  deprive  the  patient  of  the  benefit  of 
healthful  exercise,  but  in  the  case  of  an  adult  seriously  affects  him 
with  despondency,  and  an  almost  constantly  irritable  state  of  mind, 
to  the  utter  exclusion  of  any  desire  for  society  or  pleasant  inter- 
course. For  the  relief  of  this  pitiable  condition  of  the  afflicted,  we 
have  a  reasonable  excuse  for  an  adventurous  surgical  interference,  if 
it  may  be  so  considered,  when  practicing  tenotomy  for  their  relief, 
and  at  almost  any  age  of  the  patient.  Entertaining  this  considera- 
tion, we  would  advise  orthopaedists  not  to  delay  making  the  effort  to 
relieve  extreme  cases  of  contortion.  When  patient  perseverance  in 
well  devised  means  of  extension  has  failed,  sever  the  shortened  ten- 
dons and  tense  ligaments,  and  by  all  means  avoid  torturing  your 
patient  by  fruitless  efforts  at  long  continued  application  of  steel 
braces,  however  well  devised  for  the  purpose  of  extension  ;  as  the 
resisting  force  and  points  of  bearing  are  unavoidably  painful,  even 
in  cases  that  eventually  yield  to  the  treatment. 

The  chief  objection  that  has  been  advanced,  to  the  severing  of 
tendons  for  the  relief  of  contortion,  the  sequence  of  infantile 
paralysis  is,  that  it  deprives  the  limb  of  all  self-sustaining  power. 
This  statement  is  not  sustained  in  actual  practice.  That  it  has 
occurred  is  possible,  when  inexperienced  practitioners  have  severed 
tendons,  and  failed  to  devise  proper  appliances  to  sustain  the  severed 
tissue  and  limb  in  normal  position,  or  the  foot  in  relation  to  the  leg 
until  the  tendon  was  reunited.  But  we  have  never  had  a  case  in 
which  the  tendons  have  failed  to  unite,  after  having  been  severed, 
even  in  the  most  attenuated  limbs,  although  the  limb  remained  fee- 
ble for  years,  requiring  support  to  enable  the  patient  to  Aval k  —  a 
privilege  they  had  before  been  deprived  of —  and  in  nearly  every 
instance  improvement  has  been  realized  to  the  gradual  accession  of 
the  ability  to  walk  without  a  support.     This  has  been  the  result  of 


106  Or  thop^ma. 

an  experience  of  nearly  thirty-five  years  daily  devotion  to  the  treat- 
ment of  deformity,  the  result  of  various  causes,  a  large  proportion 
of  the  patients  laboring  under  this  condition  of  ailment. 

For  the  preparatory  stage  of  treatment,  requiring  the  tendons  to 
be  severed  and  apparatus  applied,  in  this  class  of  contortions  of  the 
feet  and  limbs,  we  refer  the  reader  to  the  description  given  in  the 
previous  chapter  on  congenital  contortion  of  the  feet ;  slight  vari- 
ances, we  consider,  may  be  left  to  the  intelligent  practitioner  in 
surgery. 

Mr.  William  Adams,  in  his  most  excellent  treatise  on  cluh-feet, 
published  in  1868,  pp.  41  and  43,  makes  the  following  statement  in 
regard  to  the  severing  of  tendons  in  cases,  the  sequence  of  infantile 
paralysis : 

•'  Hence,"  he  says,  "  we  can  hardly  be  surprised  to  see  a  book 
issuing  from  the  press  with  a  leading  chapter  on  '  the  impropriety  of 
tendon  cutting  and  its  evil  results/  and  with  another  chapter  on  'my 
neio  method  of  treatment ;'  but  it  is  with  no  small  degree  of  aston- 
ishment that  we  find  the  same  author,  a  hospital  surgeon,  speaking 
of  tenotomy  thus:  'The  operation  of  cutting  tendons  or  muscles 
had  been  haunting  the  domains  of  surgery  for  about  one  hundred 
and  fifty  years,  and  had  been  gradually  becoming  a  less  adventurous 
proceeding,  when,  in  1832,  Stromeyer  demonstrated  a  method  of  its 
performance  without  danger,  or  at  least,  with  very  little  danger  of 
producing  suppuration  and  sloughing.'* 

"  In  the  so-called  method  brought  forward  by  ]\Ir.  Barwell,  the  feet 
are  placed  in  an  improved  position  and  so  retained  by  means  of  tin 
splints  placed  lengthwise  down  the  leg,  and  a  series  of  elastic  india- 
rubber  cords  attached  to  the  tin  splints  and  passing  in  different 
directions  corresponding  to  the  paralyzed  muscles.  The  foot  and 
leg  are  previously  covered  with  adhesive  plaster  which  doubtless  adds 
to  the  general  support  afforded  by  the  apparatus,  and  to  some  extent 
prevents  excoriations  and  blisters  from  excessive  pressure,  which, 
however,  is  still  described  as  occurring  in  some  cases.  By  the  use 
of  these  elastic  cords,  the  author  speaks  of  supplying  an  anterior 
tibial  muscle  in  one  case,  and  o,  posterior  tibial  muscle  in  another,  or 
a  tendo-Achillis  ;  and  in  the  same  way  many  other  muscles  are  sup- 
plied, so  that  the  foot  and  leg  are  rigged  like  a  ship.     And  no  doubt 


*"0n  the  Cure  of  Club-foot  without  Cutting  Tendons,"  bv  Rich.  Barwell 
London,  1863. 


Infantile  Paral  tsis.  1 0  T 

a  very  useful  compensation  for  paralyzed  muscles  is  often  thus 
afforded ;  but  that  this  can  in  any  way  be  regarded  as  a  curative 
means  for  the  paralytic  affections  which  Mr.  Barwell  describes  as 
being  the  '  head  and  front  of  the  offending,'  has  yet  to  be  demon- 
strated. If  it  should  prove  to  be  a  means  of  cure  for  paralysis,  it 
would  be  a  valuable  addition  to  those  at  present  so  frequently 
employed  with  but  very  limited  success,  but  if  this  cannot  be  proved 
the  new  method  seems  to  be  as  little  deserving  the  unbounded  praise 
bestowed  upon  it  by  Mr.  Barwell  as  it  can  be  shown  to  have  any 
claim  for  novelty. 

"On  the  latter  point,  I  can  state  that  the  plan  was  certainly 
brought  under  my  notice  about  ten  years  ago,  by  Mr.  Bigg,  of 
Leicester  Square,  who  had  a  great  variety  of  ingeniously  constructed 
instruments  upon  this  plan,  with  vulcanized  india-rubber  cords 
attached  by  hooks  and  passing  in  various  directions  according  to 
the  deformity  for  which  the  apparatus  was  made ;  all  distortions  of 
the  feet,  knee-joint  instruments,  spinal  instruments,  etc.  Some  of 
these  instruments  for  the  treatment  of  clubfoot  were  adapted  by 
Mr.  Bigg  to  cases  in  St.  George's  Hospital,  and  he  told  me  the  chief 
difficulty  was  to  regulate  the  pressure  without  producing  sores.  The 
constant  pressure  from  the  elastic  force  could  not  be  borne  by  the 
patient,  and  the  plan  of  treatment  was  given  up,  only  to  reappear 
as  '  my  new  method '  ten  years  later. " 

The  cases  adduced  by  Mr.  Barwell  in  illustration  of  the  success 
of  the  treatment  belong  almost  exclusively  to  the  class  of  non-con- 
genital distortions  associated  with  paralysis,  or  arising  from  debility 
and  ligamentous  relaxation,  such  as  the  ordinary  flat-foot,  etc. 

This  extended  quotation  has  been  made  from  Mr.  Adams'  book,  as 
reliable  information  upon  the  credit  that  is  to  be  given  to  treatment 
by  means  of  elastic  cords  to  redress  contortions  of  the  feet.  Our  faith 
in  the  *'  new  method  "  as  a  curative  means  is  weak ;  as  all  that  could 
be  desired  in  the  treatment  of  this  class  of  ailments  has  been 
attained  by  severing  the  contracted  tendons,  i.  e.,  where  the  foot 
could  not  be  restored  to  normal  form  by  the  hand,  and  so  main- 
tained by  means  of  a  supporting  brace  without  pain.  Excoriation 
and  pain  indicate  the  necessity  of  severing  the  resisting  tissue. 


108  Oethop^dia. 

PERSOiiTAL   EFFORTS   I^ST   PRIMAJiY   TREATMENT. 

Our  primary  treatment  consists  chiefly  in  efforts  tending  to 
restore  the  normal  form  and  relative  position  of  the  limbs  to  the 
body,  as  well  as  the  maintenance  of  a  perpendicular  bearing,  and 
this  mainly  by  the  aid  of  artificial  support.  The  patient  is  to  be 
encouraged  to  make  efforts  at  locomotion,  although  at  first  consid- 
ering it  impossible.  The  attempt,  being  an  effort  of  the  will, 
imparts  a  favorable  influence,  and  the  erect  position  determines  a 
recuperative  tendency  that,  in  a  few  days,  is  most  apparent  in  nearly 
all  cases  that  present  for  treatment,  even  those  of  long  standing. 
The  feeble  circulation  and  consequent  diminution  of  temperature 
so  apparent  in  the  purplish  color  of  the  cuticle  indicates  an  enfee- 
bled capillary  circulation  in  the  impaired  limbs.  They  soon  assume, 
even  to  a  casual  observer,  a  more  natural  appearance,  and  that  too 
before  the  patient  has  improved  in  ability  to  move  the  limbs. 
Auxiliary  means  may  now  be  made  available  and  to  some  advan- 
tage, as  that  of  manipulation  by  gentle  pressure  of  the  fingers, 
commencing  at  the  extremity  of  the  limb,  and  advancing  to  the 
body  slowly,  twice  or  thrice  a  day ;  flannel  wrapped  about  the  limb 
and  covered  with  chamois  neatly  fitted;  the  limbs  washed  every 
twenty-four  hours  with  warm  water  and  soap,  and  the  application, 
by  means  of  a  suitable  covering,  of  the  dry  vapor  of  burning  spirits. 
An  India-rubber  sack  is  a  convenient  means  for  this  purpose,  and 
also  serves  another  purpose,  that  of  applying  an  air  pump  securely 
to  one  end,  and  exhausting  the  air ;  by  this  means  the  veins  become 
turgid  and  the  capillary  circulation  improved. 

Electricity,  as  described  in  another  chapter,  may  be  used,  and 
varied  to  meet  certain  indications  that  present.  If  it  tends  to 
impair  the  increasing  power  of  the  limbs,  which  it  will  in  some 
cases,  or  increases  the  contractile  power  of  the  shortened  muscles, 
it  must  be  discontinued.  Passive  exercise  by  means  of  ingeniously- 
contrived  and  complicated  fixtures  may  be  used,  a  practice  known 
as  the  Swedish  movement  cure.  This  means  of  passive  exercise  we 
do  not  approve  of  as  a  curative  means,  as  its  general  reputation 
would  warrant.  Long  experience  has  impressed  us  most  favorably 
with  the  treatment  we  have  described,  and  we  believe  that  the  close 
observer  of  the  practice  we  have  adopted  will  not  be  disappointed 
in  the  result  when  patiently  and  skilfully  applied.  As  all  excesses 
in  the  treatment  must  be  carefully  avoided  by  close  observation 


Infantile  Paralysis.  ]^09 

upon  the  patient's  condition  under  the  same,  which,  to  insure  suc- 
cess, demands  most  careful  modification,  as  in  that  of  all  other 
efforts  to  restore  energy  to  the  enfeebled  muscular  tissue. 

It  must  be  borne  in  mind  that  nearly  all  cases  of  infantile  paraly- 
sis, although  terminating  in  contortion  and  impairment  of  the 
normal  development  of  the  muscular  tissue  tend,  even  without  cura- 
tive interference,  to  recovery,  inviting,  as  it  were,  skilful  assistance 
to  the  resumption  of  a  normal  condition,  slow  in  extraordinary 
cases,  and  greatly  retarded  when  unsJiilfally  treated  (as  great  injury 
may  be  sustained  from  excessive  treatment). 

In  fact,  recovery  often  ensues  in  cases  where  no  treatment  has 
been  attempted,  and  in  nearly  all  cases  of  long  standing  we  are 
informed  of  improvement  having  taken  place,  as  that  of  a  recov- 
ered arm  or  leg,  or  one  side,  or  the  recovery  of  the  ability  to  walk, 
both  legs  having  been  paralyzed. 


FAKALYSIS   THE    RESULT   OF    CABLES    OF    THE    LAST    CERVICAL    AJSTD 
FIRST    DORSAL    VERTEBRyE. 

A  very  common  cause  of  paraplegia  in  children  is  caries  of  the 
spine  when  aflFecting  the  last  cervical  and  first  dorsal  vertebrae. 
Nearly  every  patient  thus  afflicted,  if  timely  support  is  not  given  to 
sustain  the  superincumbent  weight  of  the  head,  will  be  found  in  a 
paralyzed  condition  —  the  paraplegia  being  more  or  less  complete. 
These  cases  are  relieved  by  the  application  of  vertical  support  to  the 
head,  when  in  the  incipient  stage  of  the  ailment.  Perfect  restoration 
to  the  ability  to  walk  has  been  afforded  within  a  month  from  the  time 
of  the  application  of  the  support.  From  this  ready  means  of  relief 
we  are  disposed  to  attribute  the  cause  of  paraplegia  to  a  congested 
condition  of  the  tissues  in  that  region,  making  an  impression  upon 
the  nervous  centres  or  spinal  cord  in  a  remarkable  manner  not 
heretofore  considered  by  pathologists,  as  the  paraplegic  condition 
■ensues  before  angular  curvature  presents,  that  would  tend  to  mechan- 
ical pressure  upon  the  spinal  cord;  and  relief  afforded  as  before 
stated  by  extension  of  the  spinal  column.  What  is  most  remarka- 
ble in  this  pathological  invasion  is  because  of  the  paralysis  only 
affecting  the  lower  extremities  and  in  exceptional  cases  the  pelvic 
viscera  as  evinced  in  incontinence  of  urine,  and  more  rarely  impair- 
ing the  retentive  power  of  the  sphincter  ani ;  patients  thus  afflicted 


110  Orthop^bia. 

having  the  perfect  use  of  them,  and  no  functional  impairment  of 
the  heart,  lungs  or  stomach. 


PARALYSIS   THE    EESULT   OF    ADVENTUEOUS   TREATMEKT. 

Traumatic  injuries  of  the  dorsal  and  lumbar  vertebra  tend,  if 
severe,  in  most  instances,  to  paraplegia,  or  clonic  spasm,  which  is 
but  seldom  the  sequence  of  caries  of  the  spine,  unless  in  cases  where 
violent  effort  has  been  made,  with  the  intention  of  redressing  the 
angular  curvature,  after  it  has  existed  for  a  considerable  time.  Such 
cases  we  have  witnessed  after  adventurous  treatment,  and  subse- 
quently have  restored  the  patients  by  re-establishing  and  maintain- 
ing the  projection  by  means  of  mechanical  appliances.  This  is  an 
important  fact  to  be  remembered  in  the  treatment  of  caries  of  the 
spine.  Parents  having  children  thus  afflicted  are  exceedingly 
anxious  to  have  the  distortion  of  the  spine,  even  on  a  venture, 
restored  to  normal  form,  and  for  that  purpose  resort  to  persons  who 
make  such  pretensions.  A  case  in  point  may  more  fully  impress 
the  reader  with  the  importance  of  avoiding  such  treatment.  A 
revereud  gentleman  of  eminence  in  this  city,  brought  his  little  son, 
a  boy  seven  years  of  age,  for  treatment,  the  fifth,  sixth  and  seventh 
dorsal  vertebrae  being  diseased.  An  examination  revealed  the  pro- 
jecting spine  in  the  dorsal  region,  and  a  course  of  treatment  was 
improvised.  A  brace  was  applied,  consisting  of  lateral  support  from 
the  axillae  to  the  crest  of  the  ilium,  but  avoiding  pressure  upon  the 
projecting  bones.  Under  this  treatment  the  child  maintained  a 
tolerable  condition  of  health,  giving  promise  of  an  arrest  of  the 
disease.  The  father  very  frequently  expressed  himself  as  desirous 
that  the  projecting  bones  should  be  depressed.  To  this  we  gave  no 
other  attention  than  to  advise  perseverance  in  the  use  of  the  sup- 
port to  the  child's  body — which  would  prevent  motion  and  conse- 
quent attrition — at  the  same  time  insisting  upon  the  necessity  of  a 
generous  diet  and  moderate  exercise  in  the  open  air.  From  this 
treatment  the  little  patient  derived  much  benefit.  The  father  finally 
ceasing  to  bring  the  ailing  child  for  advice,  as  had  been  his  custom, 
every  two  or  three  weeks.  Inquiry  was  made,  and  information 
obtained,  that  our  little  patient  had  been  placed  under  the  treat- 
ment of  a  "  doctor  who  had  straightened  his  spine,"  to  the  great 
delight  of  the  parents,  and  friends  who  had  advised  the  change  of 


Infantile  Pa  ra  l  tsis.  Ill 

treatment.  We  heard  no  more  of  the  case  for  some  years,  when  we 
were  informed,  by  a  member  of  this  gentleman's  congregation,  that 
the  aforesaid  patient  was  completely  paralyzed  from  the  attempt 
made  to  straighten  his  spine. 

In  this  condition  he  remained  for  several  years,  when  his  father 
again  made  application  to  have  his  son  placed  under  our  treatment. 
On  visiting  the  (now)  young  man,  we  found  him  in  a  most  deplora- 
ble condition ;  complete  paraplegia  had  ensued,  and  to  so  great  a 
degree  as  to  require  his  knees  to  be  tied  together,  and  a  strap 
placed  about  his  body  to  retain  him  in  the  chair  constructed  for  his 
comfort. 

The  first  step  in  the  treatment  was  to  apply  a  suitable  support  to 
his  body,  and  thus  sustain  the  projecting  spine  in  a  quiescent  con- 
dition, and  to  have  an  ointment  of  strychnia  applied  to  his  para- 
lyzed limbs  daily.  The  limbs  were  also  manipulated  and  an  irritating 
plaster  applied  to  the  lumbar  region.  This  treatment  enabled  the 
young  man,  in  the  space  of  ninp  months,  to  walk,  by  taking  hold 
of  his  father's  and  brother's  arms,  for  support ;  and  in  less  than 
eighteen  months  he  could  go  about  without  assistance  ;  firm  ossifica- 
tion having  resulted  from  the  support  applied  to  the  spinal 
column. 

This  is  only  one  case  out  of  the  many  injured  patients,  whom 
we  have  treated  to  the  entire  restoration  of  power  to  their  paralyzed 
limbs,  from  the  result  of  this  dangerous  attempt  to  redress  the 
angular  projection  by  force,  thus  interrupting  the  restorative  pro- 
cess of  ossification  by  separating  the  approaching  points  of  con- 
tact. To  whatever  extent  the  angular  projection  has  advanced, 
it  should  not  be  interfered  with,  other  than  to  render  it  support, 
and  to  the  arrest  of  motion,  that  would  interrupt  the  process  of 
ossilicaLion. 


112 


Obtrop^dia. 


Fig.  HI. 


POSTERIOR    GEXU   FLEXUM. 

This  deformity  of  the  leg  consists  in  a  relaxatiou  of  the  crucial 
ligaments  of  the  knee,  and  impaired  tone  of  the  muscles  ;  allowing 
the  head  of  the  tibia  on  its  anterior  surface  to  approximate  to  the 
anterior  surface  of  the  condyles  of  the  femur.  The  posterior  sur- 
face being  separated  to  a  greater  extent  than  is  natural,  the  leg 
curves  posteriorly,  and  the  popliteal  space  is  changed  to  an  actually 
prominent  curve,  uniform  with  that  of  the  leg  when  supporting  the 
body. 

Patients  laboring  under  this  condition  of  the  leg  suffer  much 
inconvenience  from  the  unsteady  support  of  the  knee  in  walking. 
The  weakened  limb  when  carried  forward  yields  with  a  jerk,  owing 
to  the  relaxed  condition  of  the  ligameuts  and  muscles.  The  patient 
appears  to  sink  when  taking  a  step,  and  the  very  act  of  walking  tends 
to  increase  the  deformity.     (See  Fig.  57.) 

This  condition  of  the  leg,  or  legs,  is 
common  also  in  cases  of  infantile  paralysis, 
and  the  impairment  usually  confined  to  one 
leg,  and  in  a  limited  number  of  cases  the 
knee  joints  of  both  limbs  are  implicated 
in  the  weakness.  And,  as  patients  advance 
in  age,  in  most  cases,  the  limbs  gain 
strength  in  their  deformed  condition  and 
enable  the  individual  to  walk,  though  at 
the  same  time  it  becomes  a  permanent 
deformity.  In  childhood  neaily  every  case 
,is  curable. 

The  treatment  consists  in  sustaining  the 
limbs  in  natural  form.  In  cases  of  infan- 
tile paralysis,  the  support  is  usually  re- 
quired to  extend  from  the  pelvis  to  the  sole  of  the  foot,  —  the 
joints  of  the  apparatus  being  so  constructed  as  to  limit  the  foot  to 
a  right  angle  with  the  leg,  and  the  knee  to  a  vertical  position.  The 
support  should  be  worn  night  and  day,  and  only  removed  to  manip- 
ulate the  limb,  Avhich  should  be  performed  twice  in  every  twenty- 
four  hours,  while  the  patient  is  encouraged  to  walk,  which  exer- 
cise tends  greatly  (if  not  excessive)  to  increase  the  strength  of  the 
enfeebled  muscles,  Avhen  well  supported  and  the  feet  permitted  free 
action. 


Infantile  Paralysis. 


113 


Fig.  58  represents  the  supporting   appa-  mg.  bs. 

ratus :  Two  steel  bars  to  extend  up  tlie  leg 
nearly  to  the  body,  curved  out  laterally  at 
the  knee  and  attached  at  the  upper  ends  to 
a  broad  steel  band  intended  to  half  encircle 
the  limbs  and  admit  of  adaptation  to  their 
contour,  having  a  free  attachment  to  the 
bars.  When  covered,  attached  straps  com- 
plete the  encircling  of  the  limbs,  studs 
being  riveted  into  the  steel  band  as  a  more 
desirable  means  of  fastening  than  that  of 
buckles;  the  lower  portion  consisting  of 
joints  at  the  ankles,  heel-cup,  sole-plate, 
instep  pad,  and  straps  to  secure  the  feet  to 
the  apparatus.  In  such  cases,  a  soft  roller 
should  be  applied  over  the  bars  and  back  of  the  knee-joint,  bring- 
ing the  leg  to  a  vertical  position,  then  over  the  knee  and  two  or 
three  inches  above  and  below  it.  The  support  should  be  con- 
tinued until  muscular  power  is  restored  sufficiently  to  admit  of 
taking  a  few  steps  every  day  without  the  support  of  the  braces, 
and  then  reapplying  them  again  for  more  general  exercise,  being 
very  careful  not  to  leave  off  the  supports  too  soon.  For  posterior 
curvature  of  the  leg  the  reversed  application  of  the  roller  to  that 
required  for  protruded  knee  is  to  be  made,  and  the  brace  worn 
within  a  laced  gaiter. 

The  time  required  for  the  cure  of  this  deformity  will  be  from 
five  to  ten  years  in  many  cases ;  the  limbs  having  become  attenu- 
ated, and  fatty  degeneration  of  muscles  ensued,  as  in  other  cases  of 
infantile  paralysis.  Yet  these  cases  denote  possibility  of  restora- 
tion, for  as  long  as  the  sarcolemma  maintains  its  integrity,  we 
will  have  muscular  development  under  favorable  circumstances. 
This  is  an  encouragement  to  persevere  in  the  treatment  of  all  cases 
of  infantile  paralysis.  Patients  having  failed  to  be  relieved  from 
infancy  to  the  age  of  eighteen  years,  can  be  much  benefited,  if  not 
perfectly  restored ;  also,  relaxation  of  ligaments  and  muscles,  from 
other  causes.  If  the  general  health  is  unimpaired,  the  ailment  is 
the  more  readily  cured  from  properly  constructed  surgico-mechani- 
cal  appliances.  These  remarks  apply  equally  to  the  treatment  of 
all  similar  ailments ;  electricity  and  manipulation  being  suitable 
auxiliaries  when  skilfully  applied. 


114 


Obthop^bia. 


Contraction  of  the  iliacus  and  psoas  magnus  muscles  present,  in 
some  cases,  most  obstinate  resistance  to  extension  of  the  thigh,  thus 
disabling  the  patient  from  attaining  an  erect  bearing  upon  the  limb 
to  walk.  This  is  often  the  greatest  obstacle  in  treatment,  because  of 
the  difficulty  of  applying  suitable  extension.  The  extension  frame 
we  have  recently  invented  is  a  most  successful  means  for  the 
extension  of  those  muscles. 

Fifif.  59. 


A,  The  end  of  the  frame  ;  the  i^prights  having  slots  and  screw 
bolts  to  secure  the  distal  end  of  half  of  the  bed  plate,  retained  by 
hinges  to  a  centre  support,  E.  The  bolt-head  B,  which  when 
unscrewed  leaves  the  bed-plate  suspended  by  India-rubber  webbing, 
and  leather  straps  with  holes  so  as  to  be  attached  to  studs  on  the 
cross  piece  at  the  head  of  the  upright  frame.  Thus  the  bed-plates 
can  be  elevated  or  lowered  by  an  elastic  support — each  end  being 
so  constructed.  Slots  are  seen  in  the  bed-plates  through  which 
pass  webbing  belts  to  secure  the  body  and  limbs.  C,  The  strap  for 
the  body.     D,  That  for  the  legs,  one  or  both. 

By  means  of  this  apparatus,  the  muscles  are  made  subject  to 
effectual  extension,  and  by  elastic  force,  the  hips  resting  upon  the 
central  fixed  portion,  upon  which  a  pillow  or  folded  blanket  can  be 
placed  for  protection  from  the  hard  surface,  the  body  and  legs 
being  suspended  by  means  of  the  elastic  supporting  straps,  gradua- 
ted as  may  be  desired  or  borne  by  the  patient.  From  fifteen  to 
twenty  minutes  is  about  the  extent  of  the  time  that  the  patient  can 
endure  the  extension  of  the  contracted  muscles.  Immediately  on 
the  relinquishment  of  the  extension  apparatus,  the  body  brace  and 
extension  spring  should  be  applied  to  maintain  the  limb  in  its 
improved  condition. 


Infantile  Pa  ral  tsis.  115 

INFLUENCE     OF    OCCUPATION    TENDING    TO     PARALYSIS,    AND    THE 

TREATMENT. 

In  that  peculiar  yariety  of  paralysis,  the  cause  of  which  may  be 
referi^d  to  local  exhaustion  from  long  continued  position  or  ex- 
posure to  cold  water,  as  in  some  of  the  trades,  is  limited  to  the 
wrist  and  hand  of  adults.  The  first  indication  of  the  approaching 
impairment  is  indicated  by  cramp,  and  spasmodic  twitching  of  the 
flexor  muscles  of  the  fore-arm  and  hand.  This  is  found  chiefly 
among  writers  and  painters,  as  they  are  more  subject  to  long  con- 
tinued strain  upon  the  hand  and  wrist,  though  it  is  often  met  with 
among  shoemakers,  glass-cutters,  seamstresses  and  compositors. 
These  cramps  and  twitchings  of  peculiar  muscles  are  but  the  pre- 
monition of  an  approaching  paralysis,  which  finally  ends  in  what  is 
familiarly  known  as  drop  wrist  or  drop  hand,  an  inability  to  raise 
the  hand  or  extend  the  fingers.  Eelief  from  the  malposition  tends 
largely  to  the  cure,  by  permitting  the  extensor  muscles  to  recuperate 
in  power  when  relieved  from  continued  extension,  and  for  whi<3h  we 
haA'e  devised  the  following  apparatus  : 

Fig.  60.  A  metallic  casing  partly  encircling  the  fore-arm,  and 
sustaining  a  steel  spring  that  extends  over  the  wrist  to  the  fingers; 
the  hand  and  fingers  Fig.  6o. 

being   partly     covered    Mm  % 

with  a  glove,  including  M  ■  ^  ^,^ 

the   thumb,   to  which  R         ^^  ■' ^^^^^^^^xMiJ*'---'^m 

tapes  are  attached  and  t^  /  I     /y^^\  {  i  / 

passed  through    holes  ^WfciMiiii  " I  <  , T't^^^r    S-v-Cxl/''''^ 

made     in     the    cross-  -«Hai^  ^^^XniTYV^ 

piece  on  the  end  of  the  ^""^^^lldy 

spring,   also   from  the  «€^^ 

thumb  to  the  short  piece,  there  being  holes  for  that  purpose.  These 
tapes  being  drawn  up  and  tied,  determine  the  necessary  relief  to 
the  impaired  muscles,  and  fits  the  hand  again  for  service;  the  flexor 
muscles  being  apparently  unimpaired,  or  improved  by  the  extend- 
ing force. 

This  relief  to  the  extensors  is  a  most  potent  curative  means  when 
kept  applied  day  and  night.  Light  shocks  of  static  electricity,  as 
obtained  by  friction  upon  glass,  applied  daily,  have  afforded  restora- 
tive power  after  the  failure  of  Faradization  and  the  moxa.  This 
mode  of  applying  electricity  is  represented  in  Fig.  61 


116 


Orthop^dia. 


MACHIN"E   FOR   ACCUMULATING   STATIC    ELECTEICITY. 
Mfli.  61. 


This  diagram  represents  the  electrical  machine  and  apparatus. 
A  and  B  do  not  quite  touch,  but  have  a  space  between  them,  which 
space  can  be  increased  or  decreased  by  drawing  the  rod  connecting 
B  and  0  through  the  central  ball.  By  increasing  the  space  between 
A  and  B,  the  shock  can  be  intensified  to  almost  any  desired  degree, 
from  a  small  Leyden  jar ;  but  if  a  more  diffusive  and  mild  shock  is 
desired,  it  can  be  obtained  by  substituting  the  glass  tube  J.  To  in 
sulate  the  patients,  they  can  be  placed  in  a  chair  on  the  table  G, 
which  is  supported  by  glass  legs.  By  conducting .  the  electricity 
through  the  metallic  cord  F,  alone,  and  exciting  the  electrical  ma- 
chine by  revolving  the  glass  plate,  the  patient  becomes  charged  with 
electricity.  At  the  left  hand  corner  of  the  diagram  are  representa- 
tions of  several  instruments  used  in  the  varied  modes  of  applying 
electricity  to  patients.  H  is  a  metallic  brush  that  will  draw  numer- 
ous sparks  when  held  at  a  slight  distance  from  the  insulated  patient, 
when  fully  charged  with  electricity.     I  is  a  glass  tube  having  a  wire 


Infantile  Paral tsis.  1 1  T 

passing  through,  and  supported  bj  a  handle  for  applying  electricity 
to  internal  parts.  K  is  a  pointed  wire  inserted  into  a  handle,  and 
serves  to  draw  off  electricity  silently  from  the  insulated  patient, 
tending  to  produce  absorption  of  enlarged  glands  and  relieve  spas- 
modic tension  in  muscles.  L  serves  to  discharge  the  Leyden  jar 
by  applying  one  ball  to  the  body  of  the  jar  and  the  other  ball  to  the 
ball  on  the  stem  entering  the  jar.  Of  the  two  balls  on  the  table 
of  the  machine,  one  is  round  and  covered  with  cloth,  and  can  be 
attached  to  the  wire  K.  The  body  of  this  ball  is  of  wood,  and 
prepared  by  having  the  whole  surface  covered  with  varnish  and 
metal  filings,  and,  when  dry,  covered  with  cloth.  This  is  used  upon 
patients  when  insulated  and  surcharged  with  electricity, 'and  is  an 
invaluable  therapeutic  agent  to  excite  the  cuticle,  or  indolent  ulcera- 
tion, and  other  indications  of  a  similar  character,  by  covering  the 
ulcer  first  with  a  cloth,  this  being  immediately  effective,  invari- 
ably improves  the  tone  of  the  capillary  circulation  locally,  and 
very  beneficially  when  applied  to  limited  parts  of  the  body  or 
limbs.  Pains  caused  by  rheumatism,  neuralgia  and  otiier  causes, 
are,  by  the  application  of  this  ball,  in  many  instances,  permanently 
relieved.  The  other  ball  is  of  wood,  and  of  an  ovate  form ;  the  base, 
or  blunt  end,  to  be  attached  to  the  wire  K.  This  is  used,  as  is  the 
other  ball,  by  the  operator  placing  his  foot  upon  the  end  of  the 
metallic  cord  attached  to  the  handle  of  the  implement  K,  and  hold- 
ing the  pointed  end  of  the  ovate  ball  at  the  distance  of  an  inch 
or  two  from  the  inflamed  part  of  the  insulated  patient,  when  it  will, 
if  repeatedly  applied,  in  many  instances  relieve  chronic  inflamma- 
tions, and  is  a  valuable  remedial  agent.  The  pointed  wire  K,  is  to 
be  used  in  a  similar  manner,  by  placing  the  foot  upon  the  cord,  thus 
conveying  the  electric  current  to  the  earth  from  the  insulated  and 
surcharged  patient,  through  the  insulated  metallic  cord,  which,  if 
attached  to  a  gas-pipe,  is  much  more  eflficient  than  when  placed 
under  the  foot  on  the  floor,  in  dissipating  the  electricity.  Electricity 
in  other  forms  can  be  similarly  applied. 

The  following  engraving  (Fig.  62)  is  a  representation  of  the  im- 
proved Holtz  static  electrical  induction  machine.  The  insulating  table 
and  manner  of  applying  the  various  modifying  forces  of  static  elec- 
tricity are  described  on  page  116.  Fig.  K  is  an  electrode  I  have  had 
made  of  baked  wood,  having  a  socket  to  receive  metal  conductors 
that  must  connect  with  the  cord  of  the  electrode.  This  wooden  elec- 
trode is  about  thirty  inches  in  length  and  covered  with  sealing  wax 


118 


Orteop^bia. 

Fig.  62. 


dissolved  in  alcohol ;  black  and  red  serves  for  ornamentation  and 
insulation.  The  length  of  the  electrode  is  essential  in  many 
instances,  the  j)atient  being  seated  on  the  instilated  table. 


RESULTS    OF    STATIC    ELECTRICITY. 

This  condition  of  the  patient  and  the  favorable  results  from  the 
use  of  static  electricity  was  of  my  earhest  experience.  Col.  I.,  of 
G-reat  Barrington,  Mass.,  was  most  seriously  afflicted,  having  syno- 
vitis affecting  nearly  every  joint  in  his  formation.  The  cause  was 
exposui'e  to  a  ininning  stream  of  cold  water  for  a  considerable  diu*a- 
tion  of  time,  in  repairing  a  mill-dam  in  the  month  of  April,  1836. 

The  first  indication  of  the  invasion,  was  an  inability  to  rotate  the 
neck,  and  then  the  back  and  thigh  joints ;  then  the  knee  and  ankle 


Infantile  Paralysis.  119 

joints,  and  finally  the  arms  and  wrists,  to  such  a  degTee  as  to  leave 
him  in  an  entirely  helpless  condition.  Then  followed  a  chronic 
diarrhoea,  that  necessitated  the  taking  of  large  doses  of  opium  to 
retain  any  nutriment.  His  complexion  was  sallow,  his  joints  en- 
lai-ged  and  painful,  but  with  no  appearance  of  superficial  inflam- 
mation. This  had  all  intervened  from  April  to  November,  when 
treatment  by  static  electricity  was  commenced  and  ajoplied  daily 
with  light  shocks,  from  the  cervical  region  to  the  extremities — the 
patient  being  placed  upon  the  insulated  table.  After  three  months' 
treatment,  varying  the  mode  of  appUcation  to  and  from  the  patient, 
the  diarrhoea  ceased  and  the  appetite  increased  ;  but  an  intolerable 
irascibihty  ensued,  with  apparent  congestion  about  the  head.  Vene- 
section was  resorted  to,  and  much  relief  and  comfort  afforded  the 
patient.  It  was  then  observed  that  he  could  again  use  his  hands 
and  had  some  power  to  move  the  elbow  and  shoulder  joints.  After 
ten  days  a  similar  condition  of  distress  ensued,  and  relief  again 
afforded  by  venesection  of  about  sixteen  ounces.  After  this  he  was 
able  to  push  a  chair  before  him  and  thus  walk.  The  joints  were 
much  lessened  in  size  and  comparatively  soft  from  that  of  almost 
cartilaginous  hardness.  From  this  time  his  physical  condition  grad- 
ually improved,  and  locomotion  became  more  and  more  tolerable,  so 
that  in  the  following  month  of  May  he  was  able  to  mount  a  horse  and 
ride,  although  his  back  and  neck  remained  partially  fixed.  At  this 
time  electricity  was  aj)pUed  twice  a  week  until  August,  he  being 
then  quite  active,  and  prepared  to  leave  home  for  the  South  to 
spend  the  winter.  He  returned  home  the  following  Sirring  and 
became  President  of  the  Housatonic  Bank.  This  was  in  1837  or  '8, 
and  ever  since  that  time  I  have  used  static  electricity  as  a  thera- 
peutic agent,  when  possible  to  obtain  it,  which  at  that  time  could 
only  be  had  in  a  dry  atmosphere.  Now,  through  the  improved  Holtz 
induction  machine,  static  electricity  can  be  obtained,  in  all  proba- 
bility, ten  months  in  the  year,  and  in  such  profuse  quantity  that  it 
can  be  made  available  to  the  most  satisfactory  degree.  And  recent 
improvements  made  by  Mr.  Berge  of  our  city,  may  tend  to  better 
results. 


CHAPTEE  V. 

ELECTRICITY  AS  A    THERAPEUTIC    AGENT    IN   THE  TREATMENT 

OF   PARALYSIS. 

Friction  upon  amber  and  glass,  or  Static  Electricity  —  Gralvanism  —  Magnetic 
Induction,  in  the  form  of  Electro  Magnetism  —  Magnetism  and  Galvanic  In- 
duction combined  —  DiflFerence  between  Static  and  Dynamic  Electricity  — 
Static  Electricity  more  extensively  useful  as  a  therapeutic  agent  —  Electric 
concussion,  how  accomplished  —  Electric  sparks  —  Electric  shock  —  Electrical 
Induction  —  Electrical  sedative  influence  —  Electrical  Rubefacient  —  What 
constitutes  Tetanus  —  The  "  Electro  Tonic  "  State  —  Electrical  Diagnosis  — 
Duchenne  on  the  interrupted  current — Remak.an  advocate  of  the  continuous 
current  —  Thorougii  knowledge  of  diagnosis  essential  to  the  operator  —  Vi- 
talizing power  of  Electricity  —  Reactive  power  —  Matteucci's  definition- — 
Alterative  action  —  Sedative  action —  Promotion  of  Nutrition  —  Promotion  of 
Secretion  —  Promotion  of  Absorption  —  Capillary  Circulation  —  Digestion 
and  Menstruation  —  Use  in  Inflammation  —  Use  in  Congestion —  Counter-irrita- 
tion, Revulsion  —  Organic  Contraction  —  Muscular  Exercises  —  It  is  imperative 
tnat  the  Practitioner  should  understand  the  direction  of  the  Electrical  Current 

—  How  to  use  the  Galvanic  Battery  —  Results  of  Static  Electricity  —  Dr. 
Golding  Bird's  valuable  and  interesting  Classification  —  Dr.  Todd's  evidence 
as  to  its  efficacy  —  Static  Electricity  as  a  remedial  agent  for  Nervous  Diseases 

—  The  Electrical  Bath  —  Dropped  Hands  —  Illustrative  Cases  of  Paralysis 
from  Lead  Poisoning  treated  by  Electricity  —  Effect  in  Rheumatic  Paralysis, 
illustrated  by  Diagnosis  of  four  patients  —  Twelve  cases  of  Paralysis  from 
various  cases  cured  —  Case  of  Hemiplegia — Irrecoverable  injury  results  from 
injudicious  treatment  either  by  static  or  dynamic  electricity  —  Case  communi- 
cated by  M.  Bemond  of  Bordeaux —  Static  Electricity  a  remedy  for  Sciatica  — 
Chorea  relieved  by  Static  Electricity  —  Testimony  of  Dr.  Hughes,  of  Guy's 
Hospital,  London  —  Amenorrhoea  —  Tumors  —  Aneurisms  successfully  treated 
by  electric  puncture  —  Opinion  of  Dr.  Maurice  H.  Col]  is,  of  this  treatment  — 
Mode  of  operation  —  Tabulated  results  —  Method  of  applying  Electricity  — 
Dr.  Duchenne,  the  first  to  apply  the  principle  of  localization  —  Faradization 

—  Electricity  in  its  two  places,  as  an  excitant  and  a  deobstruent  —  Points  of 
application  —  Contraction  of  the  muscles  a  certain  signal  of  their  electric  exci- 
tation —  M  ascular  sensitiveness,  where  most  apparent  —  Points  in  the  muscular 
system  which  should  be  avoided  in  electric  excitation  —  Galvanism  —  Its  in- 
fluence on  asthmatic  affections  —  Galvanic  influence  greater  than  Faradic  upon 
the  muscular  tissues  —  The  continuous  current,  mode  of  application  —  The 
interrupted  current  —  Faradization  —  Primary  and  Secondary  batteries  —  Elec- 
tricity only  useful  in  a  certam  class  of  ailments  —  The  nervous  condition  of 
the  patient  a  vitally  important   element  in  diagnosis  —  Partial  insensibility 


Elegtbicity  as  a  Therapeutic  Agent.  121 

not  readily  detected  by  loss  of  tractile  sense  of  the  power  of  appreciating 
heat  or  cold  —  Increased  articular  sensibility  a  diagnostic  symptom  of  paraplegia 

—  Electricity  available  in  arresting  morbid,  nervous  or  muscular  sensibility  — 
The  circulatory  system  subject  to  the  favorable  influence  of  electricity  —  Ex- 
treme muscular  or  nervous  excitement  controllable  by  electricity  —  Faradiza- 
tion a  potent  remedial  agent  —  Electricity  inadmissible  in  the  early  stages  of 
paralysis  —  In  progressive  paralysis,  electricity  may  be  used  freely  —  Contrac- 
tility of  the  muscle  the  only  benefit  derivable  from  dynamic  electricity  —  Con- 
tinuous current,  effect  on  the  nerve  —  Necessity  of  caution  in  the  use  of 
electricity  as  a  therapeutic  agent  —  The  duration  of  the  application  an  im- 
portant consideration — Abnormal  conditions  of  the  cuticle,  muscle,  or  nerve, 
not  appreciably  relieved  by  electrical  influence  —  Injurious  effects  arising  from 
a  reckless  use  of  electricity  —  Static  electricity  the  most  reliable  as  a  method 
of  relief — "Essential"  or  spinal  paralysis  in  children,  peculiar  insensibility  to 
electrical  influence  —  Electricity  not  admissible  when  persistent  contraction 
has  taken  place  —  After  restoration  to  normal  power,  electricity  an  effective 
adjunct  —  Paralysis  affecting  the  vocal  organs  immediately  relieved  by  static 
electricity  —  Influence  of  static  electricity  in  sudden  and  severe  strains  of  the 
arm  —  Progressive  atrophy,  sciatica  supervening,  relieved  by  Fowler's  solution 

—  Treatment  of    slight  injuries  —  GtENErators  of  Gtalvanic  Electricity 

—  Galvano-Faradic  Company  of  New  York  City — Portable  Galvanic 
Batteries. 


ELECTRICITY   AS   A   THERAPEUTIC   AGENT. 

We  will  here  introduce  the  subject  of  electricity  as  a  therapeutic 
agent,  the  means  of  accumulating  and  various  modes  of  applying 
it;  and  a  consideration  of  its  peculiar  action  upon  the  animal 
system,  as  well  as  the  yarious  means  by  which  it  is  developed  or 
excited — -there  being  four  different  methods  of  obtaining  electricity. 

l^he  first  mode  of  obtaining  electricity  described,  is  by  friction 
upon  amber,  then  upon  glass;  and  accumulating  it  from  the  atmos- 
phere upon  an  insulated  metallic  cylinder,  requiring,  as  we  have 
before  remarked,  various  appliances  to  the  purposes  for  which  it  is 
Intended  as  a  therapeutic  agent.  The  second  is  evolved  by  contact, 
and  chemical  reaction  in  the  form  of  galvanism.  The  tliird,  by 
magnetic  induction,  in  the  form  of  electro-magnetism,  and  fourth, 
by  combination  of  magnetism  and  galvanic  induction. 

The  first  form  is  denominated  static  electricity,  and  is  said  to  be 
stationary,  or  not  active ;  while  in  the  form  of  galvanism,  it  is  said 
to  be  dynamic,  as  being  essentially  in  movement  and  exercising 
power.  A  very  great  difference  exists  between  the  phenomena 
exhibited  by  these  two  forms  of  electricity:  the  static  having,  in  a 
high  degree,  the  properties  of  attraction  and  repulsion,  and  when 


122  Orthop^dia. 

brought  into  movement,  exercising-  great  mechanical  power;  the 
dynamic  exhibiting  its  energy  more  in  developing  heat  and  prodnc- 
ing  chemical  change.  It  is  supposed  that  this  difference  depends, 
not  on  any  essential  diversity  of  character,  but  on  the  different 
states  of  the  electricity  developed  in  the  two  methods  ;  that  excited 
by  friction  having  little  quantity,  but  great  tension  or  intensity,  by 
which  it  is  able  to  overcome  resistance,  while  that  set  in  movement 
by  contact  and  chemical  reaction  has  feeble  tension  but  large  quan- 
tity. These  terms,  however,  are  rather  conventional,  and  intended 
to  represent  certain  qualities  in  convenient  language  rather  than  to 
be  expressive  of  the  fact  —  for  it  is  by  no  means  universally  admit- 
ted that  electricity  is  a  distinct  substance  to  which  the  terra,  "quan- 
tity," is  at  all  applicable  —  unless  as  a  figure  of  speech. 

Static  electricity  is  controlled  by  many  forms  of  application,  dif- 
fering from  the  dynamic  form,  and,  as  we  believe,  more  extensively 
useful  as  a  therapeutic  agent;  producing  two  distinct  influences 
upon  the  animal  system,  an  excitant  and  a  decidedly  sedative.  The 
dynamic  is  merely  an  excitant,  not  available  in  diminishing  exces- 
sive nervous  energy,  without  impairing  vitality,  as  in  the  case  of 
insulating  patients,  and  exciting  a  powerful  current  of  static  elec- 
tricity—  surcharging  them  —  and  then  drawing  it  off  with  a  sharp 
metallic  point  connected  Avith  the  earth.  The  influence  is  so  great 
in  this  method  as  to  induce  syncope  in  delicate  persons,  as  we 
have  frequently  witnessed;  the  influence  is  only  temporary,  however, 
tending  to  a  normal  restoration  of  nervous  influence. 

Silent  current  is  the  passage  of  a  current  of  static  electricity 
iJirough  the  person,  or  a  local  part,  by  means  of  the  insulated  hand- 
conductors,  as  seen  in  Fig.  61,  applied  to  the  leg  —  the  patient  sitting 
in  a  chair  or  standing  on  the  floor,  and  not  on  the  insulated  table. 
The  hand-conductor  F,  having  the  cord  attached  to  the  prime  con- 
ductor of  the.  electrical  machine,  and  also  to  a  metallic  point  in  the 
end  of  the  handle,  is  applied  to  the  desired  part ;  the  other  hand- 
conductor  E,  having  a  cord  also  which  should  be  connected  with  the 
gas-pipe,  or  other  means  of  conducting  the  electricity  to  the  earth. 
The  points  of  the  hand-conductors,  or  electrodes,  as  they  are  now 
termed,  can  then  be  applied  to  either  side  of  a  finger,  and  the  elec- 
tricity passed  silently  through  the  joint.  This  influence  promotes 
absorption,  and  is  made  applicable  to  the  treatment  of  indolent 
swellings  and  ulcers;  it  may  be  considered  a  gentle  excitant  of  ex- 
traordinary influence. 


Electricity  as  a  Therapeutic  Agent.  123 

Electric  Concussion  is  accomplished  by  the  patient  standing  or 
sitting,  their  person  connected  with  the  prime  conductor  of  the 
electrical  machine,  which,  when  charged,  imparts  to  the  patient  an 
excessive  quantity  of  electricity;  when,  if  connected  with  the  earth, 
a  silent  current  will  pass,  as  before  described,  but,  by  separating 
the  balls  (A  and  B),  a  very  light  concussion  will  be  felt  throughout 
the  system  and  can  be  increased  to  a  painful  degree  by  increas- 
ing the  space  between  the  balls.  This  is  a  very  potent  means  of 
relief  in  a  torpid  condition  of  the  system,  or  parts,  as  that  of  a 
limb,  or  part  of  a  limb,  or  in  tumors  —  tending  to  their  dispersion. 
Persons  of  a  sedentary  habit,  and  dyspeptic,  are  much  benefited 
by  this  mode  of  having  static  electricity  applied. 

Electricity  taken  from  the  prime  conductor  to  the  lower  border 
of  the  ensiform  cartilage,  and  the  point  of  the  other  conductor  ap- 
plied to  the  region  of  the  anus  —  the  metallic  cord  attached  to  this 
conductor  passing  to  the  earth  and  a  very  decided  concussion  in- 
duced, has  relieved  most  obstinate  constipation  of  the  bowels,  and, 
in  some  cases,  has  given  permanent  relief,  the  bowels  not  being  im- 
paired, as  by  the  use  of  drastic  purgatives,  but  improved  in  tone. 
This  application  affords  much  relief  in  light  paralytic  seizures. 

Electric  Sparhs.  —  This  means  of  applying  static  electricity  is  ac- 
complished by  connecting  the  patient  with  the  earth  —  (an  impor- 
tant precaution  in  the  use  of  static  electricity,  as  the  floor  being,  in 
a  measure,  very  dry,  insulates  the  patients  and  the  effect  of  the  elec- 
tric application  is  rendered  uncertain)  —  the  necessary  preparations 
being  thus  made  and  the  electrical  machine  briskly  excited,  elec- 
tricity is  passed  from  the  prime  conductor  through  the  cord  attached 
to  a  metallic  ball  on  the  end  of  a  hand  conductor  or  electrode,  and 
by  approaching  a  part  of  the  body  or  limbs  with  this  charged  ball, 
sparks  of  electricity  strike  the  part  with  force  and  pungency.  This 
can  be  increased  or  diminished  in  severity  to  the  degree  of  cauter- 
izing the  part,  or  of  exciting  a  large  extent  of  surface,  to  the 
relief  of  neuralgia  and  rheumatism  or  other  painful  conditions, 
usually  relieved  by  rubefacients,  but  much  more  readily  than  by 
means  of  the  more  ordinary  methods. 

Electric  Shock. —  By  means  of  the  Leyden  jar  the  most  powerful 
concussion  is  given,  even  to  the  degree  of  destroying  life.  When 
the  ball  of  this  jar  is  put  in  contact  with  the  prime  conductor  of 
the  electrical  machine,  and  electricity  accumulated,  the  interior  of 
the  jar  becomes  plus  or  positively  charged,  the  outer  coat  being 


124  Obthop^bia. 

minus  or  in  an  opposite  condition.  If,  now,  any  part  of  the  patient 
is  made  tlie  medium  of  connexion  witli  a  good  conductor,  as  that  of 
metallic  cords,  and  the  hand  conductors  applied  to  the  part,  and 
the  balls  (A  and  B,  in  Fig.  61)  are  in  contact,  no  sensible  effect  will 
be  produced,  because  the  inner  and  outer  metallic  coating  of  the  jar 
are  thus  in  a  state  of  equilibrium.  The  current  being  continuous^ 
the  outer  coat  of  the  jar  being  connected  with  the  earth,  the  silent 
current  is  established ;  but  if  the  balls,  A  and  B,  are  separated,  the 
intervening  space  being  atmospheric  air  —  a  non-conductor  —  the 
electricity  accumulates  in  the  interior  of  the  jar,  and  in  quantity 
to  the  extent  of  the  metallic  surface ;  so  that,  if  a  large  jar,  the 
quantity  will  be  in  proportion,  and  at  a  certain  degree  of  tension 
will  readily  pass  from  one  ball  to  the  other  in  the  form  of  a  con- 
densed spark,  making  a  report  and  sudden  concussion  as  it  passes 
through  the  intervening  part  of  the  body  that  connects  the  inner 
and  outer  coating  of  the  jar.  The  severity  of  the  concussion  or 
shock,  as  it  is  termed,  being  in  ratio  to  the  extent  of  the  metallic 
surface  in  the  jar,  and  the  distance  the  balls  may  have  been 
separated.  Hence,  the  separation  of  the  balls  determines  the 
severity  of  the  shock  of  a  given- sized  Leyden  jar,  or  a  battery  of 
many  jars  —  even  to  the  fusing  of  the  metal  cord  through  which  it 
is  conducted. 

The  shock  being  used  as  a  curative  means  can  be  definitely  modi- 
fied by  having  a  lesser  or  greater  surface  of  glass  coated  on  both 
sides  with  tin-foil,  so  insulated  as  not  to  be  connected  by  two  or 
more  inches  from  the  metallic  surface  on  both  sides,  by  which  the 
intensity  of  the  accumulation  can  be  obtained  that  will  give  the 
shock  required.  A  glass  tube,  as  seen  at  J,  in  Fig.  61,  serves  an 
admirable  purpose  for  nearly  all  curative  j)urposes  where  intensity 
is  required  with  lessened  severity.  If  care  is  not  taken  to  discharge 
the  Leyden  jar  before  attempting  an  operation  with  it,  there  is  a 
great  liability  of  receiving  a  severe  shock.  The  discharger,  L^ 
should  always  be  applied  to  the  ball  and  outer  coating  of  the  jar, 
and  the  jar  should  be  removed  a  proper  distance  from  the  prime 
conductor  of  the  machine. 

These  several  modifications  of  static  electricity,  we  consider  as 
excitants,  or  sedative,  and  subject  to  diffusion  or  localization. 

The  sedative  influence  of  static  electricity  is  obtained  by  insulat- 
ing the  patient  upon  glass  supports  in  the  form  of  a  table  set  upon 
glass  legs  as  seen  in  Fig.  61.     Upon  this  table  a  chaii  is  placed 


Electricity  AS  A  Therapeutic  Agent.  125 

for  the  conveuience  of  the  patient,  and  the  electrical  influence  can 
be  made  subject  to  a  variety  of  modifications. 

Electrical  Induction  consists  in  concentrating  in  a  person  insu- 
lated electricity  from  an  excited  electrical  machine.  When  the 
person  thus  insulated  becomes  surcharged  with  electricity  no 
apparent  physical  effect  is  noted,  so  long  as  he  is  undisturbed;  but 
if  he  be  approximated  by  a  metallic  ball  or  the  knuckle  of  a  second 
person  connected  Avith  the  earth,  sparks  of  electricity  will  be  trans- 
mitted, and  the  sensation  felt  by  both  parties,  i.  e.,  if  the  knuckle  be 
the  medium,  will  be  equal ;  the  severity  of  the  shock  will  be  in  pro- 
portion to  the  amount  of  electricity  accumulated  by  the  machine. 

Electrical  Sedative  Influence  is  obtained  by  withdrawing  from  a 
patient  insulated,  electricity,  by  means  of  a  metallic  point  or  points 
secured  by  a  good  conducting  material.  This  depresses  nervous 
■energy  to  a  very  decided  degree.  Delicate  persons,  or  persons  in  a 
feeble  condition  of  health  are  liable  to  syncope  if  several  points  are 
used  for  withdrawal  of  the  electricity.  The  first  effect  produced 
upon  the  person  is  an  increase  in  the  size  of  the  veins  of  the  part 
approached  by  the  metallic  points,  and,  after  a  time,  a  general 
dejtression,  quite  apjjarent  in  the  person,  will  be  produced;  or,  if 
suffering  from  local  inflammation  and  pain,  the  congested  condition 
of  the  part  will  be  reduced,  and  the  j^ain  cease  for  a  time. 

For  this  purpose,  the  hand  conductors,  H  or  K,  serve  the  pur- 
pose. The  conductor,  I,  serves  for  ap^olying  or  drawing  off  electricity  ' 
from  internal  parts,  the  metallic,  pointed  wire  being  insulated  within 
a  glass  tube  and  prepared  with  an  insulated  metallic  cord  to  be 
attached  to  other  electrical  apparatus.  Wooden  points  varied  from 
sharp  to  that  of  an  ovate  form,  as  seen  on  the  table  of  the  electrical 
machine.  Fig.  59,  are  used  for  modifying  the  intensity  of  the  elec- 
tricity when  drawn  from  sensitive  parts — an  inflamed  eye  foi 
instance. 

Electrical  Ruhefacient.  —  This  excitant  effect  is  produced  by  a 
u  disc  of  dry  wood  having  one  face  sprinkled  with  metal  filings, 
secured  by  varnish,  and  covered  with  cloth.  The  disc  is  so  con- 
structed as  to  connect  the  filings  with  the  metallic  conductor  carry- 
ing off  the  electricity.  The  patient  being  insulated  and  the  electri- 
cal machine  excited,  the  operator  passes  this  disc  over  the  diseased 
part,  exciting  a  warm,  pungent  sensation  that  can  be  increased  to 
painfulness. 

These  varied  conditions  of  the  application  of  static  electricity  are 


126  Orthop^jjia. 

only  preparatory  to  various  modifying  effects  to  be  obtained  in 
accordance  with  the  desire  and  judgment  of  the  practitioner ;  dif- 
fering from  that  of  dynamic  electricity  in  its  availability  to  the 
practitioner  as  a  means  of  controlling  the  various  morbid  condi- 
tions of  nervous  energy  —  as  that  of  deficiency  or  excess,  —  without 
permanently  impairing  the  normal  conditions  of  tissues  or  organic- 
functions.  It  is,  apparently,  congenial  to  organized  matter  and  ia 
consonance  with  the  atmosphere,  from  which  it  is  obtained,  and 
which,  when  concentrated,  it  decomposes  the  air ;  eliminating  ozone,, 
a  desirable  disinfectant  readily  detected  by  the  sense  of  smell.  Statics: 
electricity  is  a  powerful  tlierapeutic  agent,  requiring  not  only  a 
profound  knowledge  of  the  natural  laws  regarding  it,  but  an  equal 
knowledge  of  anatomy  and  physiology.  If  applied  locally  to  the- 
muscles,  their  origin  and  insertion  must  be  known  to  the  operator,, 
and  if  made  to  act  through  the  nerves,  then  their  connection  with 
the  nervous  centres,  their  course,  anastomoses  and  termination,  also,, 
of  the  laws  which  regulate  the  electrical  currents  in  the  muscles. 
and  nerves,  and  the  i-elation  of  these  laws  to  the  vital  and  physical 
forces.  This  applies,  equally,  to  all  the  devices  for  generating  elec- 
tricity, and  its  application  as  a  remedial  therapeutic  agent. 

The  recent  discovery  of  laws  that  govern  electricity  as  a  thera- 
peutic agent  of  determined  influence  upon  the  muscles  and  nerve- 
tissues,  and  the  relation  of  these  laws  to  the  vital  and  physical  forces 
establishes  it  within  the  circle  of  scientific  acceptation.  Mettucci, 
Becquerel,  and  Du  Bois  Reymond  have  discovered  and  promulgated 
the  methods  of  their  discovery. 

A  single  electrical  shock  may  last  only  the  one-thousandth  part: 
of  a  second,  but  the  muscular  shortening  reaches  its  maximum  and 
returns  to  its  former  state  in  about  one-fourth  of  a  second.  If  two- 
shocks  are  given,  the  one  immediately  after  the  muscle  has  shortened 
to  a  state  of  rest,  then  there  are  two  contractions.  If  the  second 
stroke  is  given  during  the  muscular  movement  caused  by  the  first,, 
and  there  is  either  contraction  or  relaxation,  it  causes  increased 
shortening.  But,  if  the  second  stroke  follows  very  rapidly  on  the- 
first  (that  is,  within  the  one-thousandth  part  of  a  second),  the- 
shortening  is  not  greater  than  with  one  stroke.  If  several  shocks- 
are  given  before  a  muscle  has  time  to  be  relaxed,  it  becomes  hard 
and  permanently  contracted,  constituting  tetanus.  The  less  fatigued 
the  muscle,  the  more  rapid  is  the  shortening.  Interrupted  currents,. 
or  shocks,  of  electricity,  therefore,  cause  permanent  or  tetanic  spasma 


Blectricity  as  a  Therapeutic  Agent.  127 

in  muscle,  whether  applied  directly  to  itself,  or  indirectly,  through 
a  nerve,  and  the  intensity  of  this  will  depend  on  (1)  the  intensity 
and  rapidity  of  the  current;  (3)  the  amount  of  contractile  power  in 
the  muscle ;  and  (3)  the  mechanical  resistance  the  muscle  may  have 
to  overcome,  as  from  the  distance  or  weight  of  parts  to  which  it  may 
be  attached.  On  the  other  hand,  a  continuous  current  of  electricity 
only  excites  muscular  contraction  when  the  electrical  current  is 
closed  or  broken.  In  the  interval  it  seems  to  flow  through  the  tis- 
sues without  causing  any  sensible  effect. 

When  a  continuous  current  of  electricity  is  caused  to  pass 
through  a  portion  of  a  nerve,  it  is  thrown  into  a  peculiar  condition, 
which  Du  Bois  Eeymond  calls  an  "electro-tonic"  state.  If  this 
current  is  sent  through  a  portion  of  a  nerve  in  the  same  direction 
as  its  own  proper  current,  then  the  latter  is  increased,  as  may  be 
shown  by  the  galvanometer,  but  if  in  the  opposite  direction,  it  is 
diminished.  Again,  where  the  nerve  comes  in  contact  with  the  posi- 
tive electrode,  or  conductor,  the  electro-tonic  state  is  diminished 
and  the  effect  termed  an  electro  ton  us :  where  it  comes  in  contact  with 
the  negative  electrode  it  is  increased  and  termed  "  catelectrotonus." 
Between  the  poles,  or  conductors,  at  the  point  where  the  two  oppo- 
site conditions  of  electricity  meet  (the  point  of  indifference)  the 
normal  state  of  the  nerve  is  preserved.  Both  the  increased  and 
diminished  excitability  of  the  nerves  so  caused  bear  a  relation  to 
the  force  and  rapidity  of  the  current.  Further,  the  power  of  con- 
duction in  the  nerve  is  diminished  in  the  state  of  anelectrotonns, 
but,  on  breaking  the  current,  the  conducting  power  returns  there, 
while  it  is  diminished  where  formerly  it  was  in  the  state  of  catelec- 
trotonus. Hence,  we  can  influence  the  contraction  of  muscles  by  the 
continuous  current  through  the  nerve  according  to  its  force  and 
direction.  It  can  also  be  easily  shown  that  the  farther  from  a 
muscle  a  motor  nerve  is  irritated,  the  greater  is  its  excitability,  so 
that  a  feeble  current  applied  to  a  nerve  at  a  distance  from  a  muscle 
will  excite  more  contraction  than  a  stronger  one  applied  close  to  it. 
The  stimulation  of  sensitive  nerves  by  electricity  excites  their  special 
function,  on  the  forming  and  breaking  a  current,  in  proportion  to  its 
amount  and  rapidity.  Hence,  we  can  excite  pain  through  the  ordi- 
nary sensitive  nerves,  flashes  of  light  through  the  optic,  noise 
through  the  auditory,  and  taste  through  the  gustatory  nerves.  Aa 
with  muscles,  also,  during  the  interval,  no  sensible  effect  is  occa- 
sioned.   These  laws  of  electrical  influence  on  the  animal  system  have 


128  Oethop^dia. 

been  promulgated  as  the  result  of  careful  investigation  made  by 
some  of  the  most  reliable  and  noted  electricians,  and  apj)lied  to 
electrical  diagnosis  tending  to  the  most  invaluable  results  in  the 
practice  of  mediciue. 


ELECTRICAL   DIAGNOSIS. 

"With  regard  to  the  proper  method  of  appiymg  electricity  in 
disease,  great  difference  of  opinion  prevails.  Duchenne  strongly 
supports  the  use  of  an  interrupted  current  applied  locally  to  the 
muscles,  while  Remak  maintains  the  importance  of  a  strong  con- 
tinuous current  applied  to  the  nerves  and  nerve  centres.  Both 
modes  of  procedure  require  to  be  more  generally  tested  by  experi- 
ence. In  one  class  of  cases  originating  in  the  nervous  centres,  as 
in  hemiplegic  paralysis,  Remak's  plan  may  be  most  useful ;  whereas, 
in  another  class  depeuJeut  on  a  primary  morbid  action  affecting 
the  muscles,  as  i]i  lead  paralysis,  that  of  Duchenne  may  prove 
best.  It  has,  also,  to  be  ascertained  what  is  owing  to  direct  and 
what  to  reflex  action  during  the  topical  application  of  electricity. 
A  thorough  knowledge  of  diagnosis  should  be  possessed  by  him  who 
undertakes  the  difficult  task  of  employing  so  powerful,  although 
manageable  an  agent  for  the  relief  and  cure  of  diseases.    (Bennett.) 

Attempts  have  been  made  to  employ  the  sensations  produced  by 
electricity  in  traversing  diseased  parts,  as  a  means  of  diagnosis. 
Although  nothing  reliable  has  been  accomplished  in  this  direction, 
the  fact  is  well  known  that  the  tissues  and  nerves  which  are 
inflamed  or  otherwise  diseased  are  often  more  sensitive  to  the  pas- 
sage of  electricity  than  those  in  a  healthy  state.  Some  discrimina- 
tion may  also,  probably,  be  made  as  to  the  character  of  sensation  in 
different  conditions  of  disease.  This  has  suggested  the  idea  of 
determining  the  position  and  nature  of  internal  lesions  by  the  elec- 
trical current.  Diseases  of  the  spine  and  of  the  lungs  are  examples 
of  cases  in  Avhich  this  experiment  has  been  made.  The  idea  of  thus 
probing  deep-seated  organs,  is  one  of  interest,  and  calculated  to 
awaken  inquiry.  In  some  cases,  the  rapid  administration  of  electro- 
magnetism  would  be  available  for  this  purpose,  but  for  nice  distinc- 
tions, the  continuous  current  of  the  battery  would  obviously  be 
preferable. 

Vitalizing  power. —  One  of  the  most  common  objects  of  electrical 


Electricity  AS  A  Therapeutic  Agent.  129 

application  is  to  co-operate  with  vitality.  This,  indeed,  may  be 
considered  the  central  principle  in  the  medical  use  of  electricity. 
In  the  nervous  system  it  is  illustrated  in  cases  of  exhaustion,  pros- 
tration, enervation  and  paralysis ;  in  the  tissues,  in  gangrene,  ery- 
sipelas, in  indolent  ulcers  and  deficient  nutrition.  It  will  be  found, 
indeed,  to  enter,  more  or  less  directly,  into  every  case  of  electrical 
application.  The  idea  will  be  frequently  suggested  to  the  prac 
titioner,  by  his  own  observation,  that  the  agent  electricity  works  in 
the  direction  of  health,  even  in  the  most  opposite  affections.  This 
is  admitted  simply  by  the  fact,  that  its  operation  is  to  quicken  the 
vital  powers  and  natural  functions  of  the  part  to  which  it  is  applied. 
Diseased  action,  when  local,  is  perhaps  especially  controlled  by  the 
supply  of  nervous  power,  previously  different,  which  is  brought  into 
action,  connecting  and  harmonizing  functions. 

Reactive  poiuer. —  Electricity  constitutes,  in  the  hands  of  the 
medical  practitioner,  a  reactive  power.  According  to  Matteucci,  the 
nervous  system  responds  to  electricity  after  all  other  stimulants  have 
ceased  to  act.  Thus  it  has  a  very  important  application  in  sus- 
pended animation,  narcotism  and  stupor.  Another  equally  import- 
ant application,  which  has  only  beg?an  to  receive  attention,  is  that 
to  collapse,  and  the  sinking  stages  of  disease.  This  being  admitted 
from  positive  experiment,  no  practitioner  in  medicine  should  fail  to 
be  supplied  with  electrical  apparatus  of  the  most  reliable  construc- 
tion, and  an  intimate  knowledge  of  its  application  to  patients  con- 
ditioned as  above  stated. 


ELECTRICAL   INFLUENCE. 
ALTERATIVE  ACTIOJv". 

An  influence  frequently  exerted  by  electricity  is  that  of  changing 
the  action  of  an  organ,  or  the  general  tone  of  the  system,  thereby 
arresting  a  diseased  condition.  The  application  of  electricity  by 
the  sponge-handle  in  cutaneous  diseases,  is,  perhaps,  founded  on  this 
principle,  causing  the  skin  to  take  on  a  normal  action.  So,  also,  in 
some  nervous  affections,  and,  peihaps,  in  application  to  the  brain. 
As  a  simple  alterative,  electro-magnetism  is  most  generally  applied. 

SEDATIVE  ACTIOlSr. 

The  sedative  action  of  electro-magnetism  is  of  a  secondary  influ- 
ence.    The  continuous  current  of  the  battery  exerts  often  a  tran- 


130  Orthop^dia. 

quiliziug  influence,  moderating  and  equalizing  irregular  action  of 
the  nervous  system  at  the  same  time  that  it  adds  to  its  power.  Thus 
convulsions  are  quieted  by  the  steady  current,  though  increased  by 
the  intermittent  or  electro-magnetic  shock. 

PROMOTIOis"  OF  XUTRITIOX. 

In  deficient  nutrition,  electricity  may  co-operate  in  the  vital 
transformation  and  organization  of  the  nutrient  matter  by  means 
of  the  nervous  system  or  by  direct  action  on  the  tissues  of  a  part- 
To  produce  increased  action  in  the  latter  case,  static  or  galvanic 
electricity  may  be  used.  This  will  be  done  wherever  a  part  needs 
to  be  nourished,  or  the  waste  of  any  organ  to  be  replaced.  As  a 
general  rule,  tlie  battery  current  should  be  feeble,  and  the  applica- 
tion long  continued  and  frequent. 

PEOMOTIOX  OF  SECRETIOK". 

Wilson  Philip  says,  "  I  cannot  help  regarding  it  as  almost  ascer- 
tained that  in  those  diseases  in  which  the  derangements  are  in  the 
nervous  poAver  alone,  Avhere  the  sensorial  functions  are  active  and 
the  vessels  healthy,  and  merely  the  power  of  secretion,  which  serves 
immediately  to  depend  on  the  nervous  system,  is  at  fault,  galvanism 
will  often  prove  a  valuable  means  of  relief."  *  The  immediate  influ- 
ence of  galvanism  on  the  tissue  of  secreting  organs  will  also  appear 
hereafter.  The  battery  current  is  most  efiicient  for  this  application, 
but  nervous  stimulation  may  be  effected  also  by  electro-magnetism. 
The  currents  should  be  sent  along  the  nerves  supplying  the  organ 
in  the  direction  from  the  nerve  centre,  toward  the  nerve  extremities, 
Avhen  it  is  desired  to  produce  an  immediate  stimulation  of  the  func- 
tion, and,  in  the  opposite  direction,  when  it  is  desired  to  produce 
gradual  and  permanent  stimulation.  It  may,  also,  be  sent  through 
and  through  the  organ  in  different  directions.  The  strength  and 
stimulating  character  of  the  application  will  vary  with  the  condition 
of  the  organ.  In  deficient  secretion  from  the  mucous  membrane  of 
the  lungs  a  gentle  and  diffused  current  will  be  indicated. 

promotions"   of   ABSORPTION. 

In  effusions  of  serum  or  lymph  in  some  forms  of  hypertrophy,  in 
bony  deposits,  rheumatic  enlargements,  and  every  nndue  organic 
development,  with   the   exception,   perhaps,    of    some    malignant 


*  "Vital  Functions  "  2d  edition,  page  331. 


Electricity  AS  A  Therapeutic  Agent.  131 

growths,  the  power  of  the  absorbents  needs  to  be  quickened,  and 
this  may  often  be  effected  by  electrical  action.  In  this  case,  the 
application  is  usually  made  directly  to  the  organ,  though  the  rule 
still  prevails,  in  acting  through  the  nervous  system,  that  the  vital 
stimulus  artificially  supplied  directs  itself  to,  or  principally  per- 
ceived in,  that  function  whose  efficiency  is  suspended.  In  other 
words,  the  tendency  of  the  nervous  influence  seems  to  be  to  har- 
monize the  various  vital  functions,  dis|)roportionate  action  appear- 
ing thus  to  proceed  from  causes  acting  originally  on  the  life  of 
tissues.  In  serous  effusions  accompanied  with  inflammation,  the 
battery  cannot  be  used,  but  a  cautious  and  gentle  application  of 
static  electricity  will  be  effectual.  In  other  cases  of  effusion,  the 
battery  will  be  quite  efficient. 

CAPILLARY   CIRCULATION. 

The  increase  of  the  capillary  circulation  under  the  influence  of  the 
current  has  been  referred  to.  This  takes  place  in  a  very  marked 
manner  when  the  sponge  handles  are  used  in  connection  with  the 
battery.  The  skin,  in  a  short  time  after  the  application,  becomes 
warm  and  red,  especially  under  the  negative  handle  where  the  cur- 
rent passes  out  in  the  direction  of  the  nervous  organic  current. 
The  excitement  of  the  functions  of  the  skin  may  be  spoken  of  in  this 
connection.  It  will  be  seen  hereafter  that  perspiration  breaks  out 
and  warmth  is  established  in  a  part  subjected  to  the  influence  of 
the  battery.  This  takes  place  under  the  influence  of  static  elec- 
tricity or  electro-magnetism.  The  arterial  action  is  increased  by  all 
modes  of  application  and  is  especially  quickened  in  the  smaller 
vessels,  as  may  be  presumed  by  the  emotions  of  the  shock. 

DIGESTIOif   AND    MENSTRUATION. 

The  functions  of  digestion  and  menstruation  are  peculiarly  under 
the  influence  of  electricity  in  its  various  forms.  They  will  be 
treated  of  in  connection  with  other  diseases.  The  application,  in 
the  case  of  diseases  of  women,  is  so  simple  that  it-  can  generally  be 
made  without  any  very  great  experience  in  the- use  of  electricity. 

USE   IN    INFLAMMATION. 

The  tendency  of  the  battery  current  is  to  produce  increased 
organic  action ;  the  tendency  of  a  feeble  electro-magnetic  current 
is  hardly  more  than  an  alterative  stimulus,  still,  the  application  of 
dynamic  electricity  is  contra-indicated.     In  that  of  static  electricity 


132  Orthop^dia 

with  the  patient  insulated  and  the  electricity  drawn  off  by  sharp 
metallic  points,  a  sedative  condition  is  rendered  most  effective  in 
reducing  active  and  progressive  inflammation.  Dr.  Wilson  Philip 
states  as  a  result  of  microscopic  observation,  that  the  conditions  -of 
the  capillaries  in  inflammation  is  one  of  distension  and  debility, 
Avhile  the  arterial  action  is  increased.  Stimulation  of  the  capil- 
laries, therefore,  in  such  cases,  may  relieve  inflammation,  especially 
when  of  a  passive  character,  by  the  feeble  electro-magnetic  current, 
being  an  indirect  influence,  and  the  power  of  stimulating  the  capil- 
laries of  the  surface  of  the  body  is  peculiarly  within  the  province 
of  electricity  in  this  form.  In  an  advanced  stage  of  inflammation, 
'w  hen  the  capillaries  are  so  burdened  as  to  stop  the  circulation,  an 
increase  of  vital  power,  determined  by  electricity,  may  be  of  im- 
portant service.  So,  also,  electricity  may  be  summoned  to  terminate 
a  condition  consequent  upon  inflammation  which  is  only  continued 
from  want  of  reactive  j)ower. 

USE    IX    COXGESTIOX. 

The  application  of  dynamic  electricity  to  an  organ  in  the  early 
stages  of  congestion  would  be  inadmissible ;  not  so  of  static  elec- 
tricity, as  it  is  of  valuable  service  in  relieving  local  congestion,  as 
in  cases  of  inflammation.  Dynamic  electricity  in  the  latter  stages 
of  congestion  mav  prove  beneficial;  aiding  the  vital  powers  in  the 
resumption  of  the  natural  functions  of  the  organ,  if  carefully  used. 

COUXTER-IRRITATIOX,    REVULSIOK". 

An  organ  that  is  inflamed  or  congested  may  sometimes  be  relieved 
by  stimulating  another  organ  connected  with  it  by  position  or  nervous 
association.  It  frequently  happens  in  the  inflammation  of  one  organ 
that  a  neighboring  one  will  be  torpid.  A  double  relief  can,  there- 
fore, be  obtained  where  it  is  possible  to  stimulate  the  latter  without 
acting  on  the  former.  Electricity,  in  most  of  its  surface  applica- 
tions, is  easily  capable  of  being  converted  into  a  rubefacient  or 
irritant  with  the  advantage  of  stimulating  into  activity  all  the  func- 
tions of  the  skin.  It  can  also  be  directed  so  as  to  excite  specific 
internal  organs  by  static  electricity  in  the  form  of  shocks.  For 
irritating  the  skin,  the  sponge  or  metallic  handle  may  be  used  with 
the  battery,  being  kept  near  each  other  and  moved  over  the  surface, 
or,  the  metallic  plates  of  Wilson  Philip,  consisting  of  two  thin  plates 
of  metal,  two  or  three  inches  in  diameter,  upon  the  surface  of  the 


Electricity  as  a  Therapeutic  Agent.  133 

body  where  it  is  desired  to  make  electrical  communication,  may  be 
used.  The  wires  of  the  battery  are  brought  in  contact  with  these 
plates  and  constantly  moyed  over  them  —  especially  the  negative 
wire  —  to  avoid  injury  to  the  cuticle  beneath.  The  plates  are  pre- 
viously dipped  in  water,  or  a  solution  of  common  salt  —  as  should 
generally  be  done  —  in  using  the  battery  to  aid  the  diffusion  of  the 
electricity.  A  more  effectual  means  of  producing  this  result  is  from 
static  electricity  by  drawing  sparks  from  the  skin  while  the  patient 
is  on  the  insulated  stool.  It  has  been  stated  that  suppressed  erup- 
tions have  been  brought  to  the  surface  by  this  means  of  revulsion. 

OEGANIC    CONTKACTION". 

One  influence  of  electricity,  capable  of  important  applications,  is 
the  restoration  of  organic  contractility  or  tension  in  relaxed  tissues. 
This  applies,  not  only  to  muscular  tissue,  but  especially  to  the 
ligamentous  system,  including  fibrous  and  capsular  ligaments. 
Examples  of  this  will  be  given  hereafter. 

MUSCULAR   EXERCISE. 

Much  advantage,  at  times,  is  derived  from  the  effect  of  muscular 
contraction  induced  by  electricity  in  moving  organs  one  upon  the 
other ;  and,  probably,  in  an  old  inflammation,  such  as  sprains,  in 
breaking  up  adhesions.  In  the  ajoplication  of  an  interrupted  cur- 
rent to  the  abdomen,  the  parietes  are  contracted  in  a  variety  of 
directions,  as  well  as  the  muscular  fibres  of  all  the  included  organs 
which,  in  some  forms  of  dyspepsia,  is  one  of  the  most  favorable  of 
influences.  In  paralysis,  the  exercises  given  to  the  muscles  is  of 
great  importance  in  preserving  the  contractility  of  the  tissues  and 
preventing  the  loss  of  organization  and  want  of  substance,  as  in  the 
early  condition  of  the  paralyzed  patient. 

It  is  of  great  importance  to  the  practitioner  to  understand  the 
direction  of  the  current  of  electricity.  In  static  electricity,  the  cur- 
rent is  from  the  prime  conductor,  and  can  be  directed  from  the 
origin  of  a  nerve  to  its  termination  by  the  application  of  the  con- 
ductor attached  to  the  prime  conductor  (the  patient  being  insulated), 
by  any  connection  with  the  patient  and  the  earth  from  the  extremi- 
ties of  the  body.  And,  if  it  is  desired  to  reverse  the  current,  the 
conductor  attached  to  the  prime  conductor  should  be  applied  to  the 
extremity  of  a  nerve,  or  the  limbs,  and  the  conductor  connecting 
with  the  earth  to  some  part  of  the  spinal  column. 


134  Orthop^dia  . 

In  applying  electricity  from  the  galvanic  battery,  the  pole  con- 
necting with  the  copper  plate  is  the  positive  pole  or  the  entering 
pole  of  the  current;  as  that  of  the  prime  conductor  in  static  elec- 
tricity, as  regards  the  body  of  the  patient  and  the  handle  connected 
with  the  zinc  j^late,  is  the  negative  pole.  With  the  electro-magnetic 
apparatus,  the  positive  pole  is  that  which  produces  least  sensation 
when  applied  to  an  equally  sensitive  part  of  the  body  with  the  nega- 
tive. The  handles  or  electrodes  may  be  conveniently  distinguished 
by  holding  one  in  each  hand,  when  the  most  pain  and  contraction 
will  be  felt  in  the  hand  grasping  the  negative  handle,  or  that  con- 
nected with  the  negative  pole. 


EESULTS  OF  STATIC  ELECTEICITY. 

The  results  of  treatment  by  the  several  varieties  of  means  for  the 
accumulation  of  electricity  determine,  to  a  limited  extent,  their  eflB- 
ciency  in  the  cure  of  certain  pathological  conditions  of  the  body. 
Dr.  Golding  Bird,  in  Guy's  Hospital,  London,  has  applied  the  static 
electricity  the  most  extensively  of  any  of  the  practitioners  availing 
themselves  of  its  use  in  the  practice  of  medicine ;  and  upon  whom 
reliance  can  be  placed,  because  of  his  high  attainments  in  his  pro- 
fession. The  following  is  a  synopsis  of  a  few  of  the  cases  given  in 
his  valuable  reports  of  treatment  of  patients  with  static  electricity 
in  Gruy's  hospital. 

Static  electricity  has  long  been  in  the  hands  of  adventurers  in  the 
treatment  of  paralysis,  and  in  many  instances  with  extraordinary 
success,  inviting  the  attention  of  the  learned  and  discriminating  in 
the  science  of  medicine.  Dr.  Golding  Bird,  from  his  large  experi- 
ence, classifies  the  folloAving  forms  of  paralysis  that  are  relieved  by 
the  judicious  application  of  static  electricity.* 

1.  Partial  paralysis  from  organic  congestion  or  eifusion,  which 
has  been  removed.  2.  Paralysis  of  the  portia  dura,  of  the  seventh 
pair,  from  exposure  to  cold.  3.  Paralysis  of  a  limb  from  the  same 
cause,  4.  Paralysis  of  one  side  of  the  body,  or  a  single  limb,  from 
exhaustion  —  as  from  lactation,  and  flooding.  5.  Paraplegia  from 
rheumatism,  paraplegia  from  enervation. 

He  found  the  use  of  electricity  most  successful  in  recent  cases, 
and  contends   against  its  use  in  many  of  the  established   organic 

*  London  Lancet,  June,  1846. 


Electricity  as  a  Therapeutic  Agent.  135 

lesions;  stating  that  he  has  known  fatal  apoplexy  to  follow  its 
application  in  cases  of  ramolissement  of  the  brain,  or  where  indur- 
ated arteries  existed.  And,  moreover,  he  remarks  that  he  has  never 
known  electricity  to  do  any  good  in  rigid  flexion  of  the  thumb  or 
fingers. 

Under  various  modes  of  electrical  application  we  find,  however, 
that  paralytic  contraction  has  been  successfully  controlled  in  cases 
of  diminished  tone  in  certain  sets  of  muscles  impaired  by  long- 
continued  extension,  that  impairment  of  the  balancing  muscular 
force  having  even  tended  to  contortion. 

Dr.  Bird  remarks:  "From  the  want  of  exercise,  the  muscles  of 
the  affected  limb  become  atrophied.  The  power  of  electricity  in 
this  respect  is  very  remarkable  ;  frequently  restoring  power  to  the 
paralyzed  muscles  in  a  very  short  time." 

Dr.  Todd,  in  a  paper  in  the  Medico-Chirurgical  Transactions  of 
1847,  from  a  large  number  of  observations,  arrives  at  the  following 
conclusions  :  1.  That  irritability  of  paralysed  muscles  is  in  direct 
relation  to  their  state  of  nutrition.  2.  It  varies  with  the  condition 
of  nerves  more  than  with  that  of  the  muscles  themselves.  3.  In  a 
majority  of  cases  of  cerebral  palsy,  the  contractility  of  the  par- 
alyzed muscles  is  less  than  that  of  the  muscles  of  the  sound  side 
on  account  of  diminished  nutrition.  4.  No  diagnostic  mark  to 
distinguish  cerebral  from  spinal  paralysis  can  be  based  on  any  differ- 
ence in  the  irritability  of  the  muscles.  5.  The  irritability  of  para- 
lyzed muscles  under  the  influence  of  galvanism  is  an  index  to  the 
state  of  their  nerves.  This  applies  equally  to  static  electricity. 
These  are  indications  to  be  carefully  considered  in  the  use  of  elec- 
tricity as  a  therapeutic  agent. 

In  regard  to  the  efficiency  of  static  electricity,  Dr.  Golding  Bird 
expresses  his  favorable  opinion  of  its  use  in  the  treatment  of  ner- 
vous diseases,  of  which  we  will  give  a  synopsis.  His  mode  of 
applying  electricity  is  by  insulating  the  patient.  In  regard  to  the 
drawing  off  of  electricity,  silently,  in  connection  with  the  earth,  he 
remarks:  "During  the  discharge,  heat  is  evolved,  the  circulation 
becomes  quickened,  the  secretions  generally  become  more  active, 
and  perspiration  breaks  out.  A  person  thus  situated  is  said  to  be 
in  an  electrical  lath ;  and  it  is  by  no  means  improbable  that  this 
might  be  frequently  employed  with  advantage  in  certain  affections 
in  which  the  functtons  of  the  skin  and  nervous  membranes  are 
deficient." 


136  Or  thop^dia  . 

Dr.  Bird's  most  common  mode  of  applying  the  static  electricity 
was  by  insulating  the  patient  and  drawing  off  sparks,  which  method 
is  subject  to  much  modification  by  drawing  heavy  or  light  sparks  ; 
and  from  various  parts  of  the  body  and  limbs,  but  more  especially 
from  the  spinal  column. 

Paralysis  of  the  extensors  of  the  hands  from  lead  poison,  known 
as  dropped  hands,  are  mentioned  by  Dr.  Bird  in  his  reports  in  which 
he  refers  to  eleven  of  these  cases  treated  by  static  electricity.  Five, 
he  says,  were  cured,  three  relieved,  and  one  improved ;  two  received 
no  benefit  whatever.  Sparks  were  generally  drawn,  in  these  cases, 
from  the  upper  part  of  the  spine  while  tlie  patient  was  seated  on 
the  insulating  stool  in  order  to  influence  the  axillary  plexus.  Four 
of  these  cases  are  most  worthy  of  n'ote : 

1.  A  compositor,  aged  nineteen.  Paralysis  of  the  extensors  of  both 
hands,  with  amaurosis,  preceded  by  an  attack  of  lead  colic.  After 
four  months  of  interrupted  treatment  the  paralysis  was  cured,  but 
the  amaurosis  remained,  though  the  pupils,  previously  nearly  insen- 
sible, contracted  and  dilated  readily. 

2.  A  cooper,  aged  twenty-nine,  with  recent  and  complete  paralysis 
of  extensors.  Weak  shocks  from  the  spine  down  the  arm.  Withip 
a  month,  able  to  resume  his  work. 

3.  A  painter,  aged  twenty-seven.  Complete  paralysis  of  extensors. 
In  fifteen  days  discharged  — well. 

4.  A  plumber,  aged  thirty-six,  with  total  paralysis  of  the  exten- 
sors of  a  year's  standing.  Shocks  down  the  arms  on  alternate  days. 
No  improvement  after  twenty  days.  Sparks  ordered  to  be  drawn 
from  the  spine.  In  sixteen  days,  great  improvement,  and  soon  able 
to  resume  work. 

We  have  treated  many  cases  of  these  ailments,  arising  from  lead 
poisoning,  successfully,  with  static  electricity  alone.  In  obstinate 
cases  we  have  given  the  patients,  in  divided  doses,  twenty  grains, 
daily,  of  antim.  sulph.  aur.,  or  the  hydro-sulphuret  of  antimony, 
which  we  believe,  from  tiie  relief  afforded  patients  thus  affected,  to 
be  of  great  benefit.  In  fact,  patients  were  perfectly  cured  by  this 
medicine,  and  without  the  assistance  of  electricity,  but  not  in  so 
brief  a  period  as  when  electricity  was  made  a  part  of  the  treatment. 

As  we  have  before  stated,  dropped  hands  are  often  the  result  of 
long  continued  position  of  the  hands  in  a  state  of  tension,  as  occurs 
in  some  occupations  when  closely  applied  to  labor ;  shoemakers, 
clerks,  and  persons  engaged  on  fine  needle-Avork,  or  any  similar  em- 


Electricity  AS  A  Therapeutic  Agent.  137 

ployment  requiring  the  fingers  to  be  flexed  and  long  retained  m  a 
state  of  tension.  Of  this  class  of  patients,  nearly  every  one  is  per- 
fectly curable  with  static  electricity,  and  often  after  dynamic  elec- 
tricity has  failed. 

In  the  treatment  of  this  variety  of  partial  paralysis  of  the  fore- 
arm and  hand,  we  but  seldom  insulate  the  patient,  and  simply  pass 
light  shocks  from  the  elbow  to  the  extremities  of  the  fingers,  having 
an  elastic  spring  support  applied,  to  keep  the  hand  extended  by 
elastic  support.  Erom  this  treatment  of  patients,  under  fifty  years 
of  age,  laboring  under  this  ailment,  we  know  of  no  failures  to 
improve  the  condition  of  the  arm  and  hand,  although  a  great  num- 
ber present  for  treatment,  every  year,  at  the  Hospital  for  the  Eelief 
of  the  Ruptured  and  Crippled. 

Dr.  Bird  speaks  of  the  most  remarkable  influence  from  static 
electricity  in  rheumatic  paralysis  before  the  wasting. of  the  muscle. 
Out  of  ten  of  these  cases,  only  two  failed  to  be  relieved  and  cured. 
This,  by  far,  exceeds  any  other  treatment  in  its  curative  tendency. 
The  treatment  of  four  cases  was  as  follows  : 

1.  A  boy  of  fifteen  years,  with  paralysis  of  motion  of  right  arm, 
preceded  by  pain  and  swelling  of  the  neck.  Medical  treatment  for 
nine  months  without  benefit.  Twelve  shocks,  daily,  from  the  liey- 
den  jar,  to  be  passed  from  the  cervical  vertebrse  to  the  fingers.  In 
two  months  discharged  cured. 

2.  A  sailor,  aged  thirty-two.  Paralysis  of  right  arm  and  both  hands 
from  cold  affusion  in  fever.  Sparks  to  be  drawn  from  spine  and  para- 
lyzed muscles  three  times  a  week.     In  seven  weeks  discharged  cured. 

3.  A  man,  aged  thirty-eight,  with  entire  paralysis  of  motion  of 
right  leg,  following  rheumatism.  Sparks,  alternate  days,  from  the 
lumbar  vertebrae  and  limb.     In  six  weeks  discharged  cured. 

4.  A  man,  aged  thirty,  with  paralysis  of  motion  of  both  hands 
from  effects  of  cold  water.  Sparks  from  spine  and  hands.  After  a 
few  applications  returned  to  his  work. 

Twelve  cases  of  paralysis  from  various  causes  treated  by  Dr.  Bird 
in  Guy's  Hospital  resulted  as  follows  : 

1.  A  man,  aged  thirty,  with  hemiplegia  of  right  side,  of  nine 
months'  standing,  induced  by  a  fall  in  which  he  struck  his  head. 
Paralysis  partial.  December.  Shocks  to  be  passed  twice  a  week 
from  the  spine  down  leg  and  arm.     Cured  in  April. 

2.  A  woman,  aged  twenty-six,  with  paraplegia,  following  a  recent 
apoplectic  attack.     After  several  months'  medical  treatment,  con- 


138  Obteop^bia. 

dition  unimproved.     Sparks  ordered  from  the  lumbar  vertebrse  and 
legs.     Eapid  recoverv  ensued. 

3.  A  woman,  aged  fifty-two,  with  partial  paralysis  of  motion  and 
of  feeling  of  right  arm.  Under  common  treatment  for  three  months, 
sensation  had  improved.  December  20.  Electro-magnetic  current 
ordered  from  neck  to  fingers  thrice  a  week.  January  20.  Motion 
much  improved.     February  20.     Cured. 

4.  A  waiter,  aged  forty-six,  with  paralysis  of  motion  of  right  half 
of  the  body,  with  some  loss  of  sensation,  of  three  months'  standing. 
September  22:  Twelve  shocks,  on  alternate  days,  down  the  back 
and  limbs.  October  31 :  iSTumbness  of  only  one  finger  remaining. 
Eeturned  to  his  work. 

0.  A  smith,  aged  twenty-two,  with  recent  complete  paralysis  of 
motion  of  right  arm.  August  4 :  Sparks  to  be  drawn  from  the 
upper  part  of  the  spine  and  arm.     September  1 :  Cured. 

6.  A  boy,  eleven  years  old,  with  complete  paralysis  of  motion  on 
the  right  side,  of  seven  weeks'  standing.  Sparks  were  drawn  from 
spine  and  limbs.  After  first  application,  walked  back  into  the  ward 
with  the  aid  of  a  stick.     In  a  few  days  completely  cured. 

7.  A  coal  porter,  with  paralysis  of  right  arm  and  face.  November 
29 :  Sparks  from  spine,  face  and  arm.  December  24 :  Arm  cured. 
Electro-magnetic  shocks  to  face  in  direction  of  branches  of  fifth 
pair.     January  10:  Much  improved. 

"We  have  treated  many  similar  cases  with  static  electricity,  differ- 
ing somewhat  in  the  application,  but  with  quite  equal  success.  Dr. 
Bird's  experience  fully  confirms  our  own  in  nearly  thirty  years'  prac- 
tice in  the  use  of  electricity  in  its  various  modifications,  and  we  have 
been  most  favorably  impressed  with  static  electricity  as  a  curative 
means,  though  requiring  great  care  in  its  application.  We  have 
seen  patients  irrecoverably  injured  by  injudicious  treatment  with 
both  static  and  dynamic  electricity.  Matteucci  has  pointed  out  the 
entire  exhaustion  of  nervous  power,  similar  to  paralysis,  resulting 
from  an  excessive  use  of  electricity.  If  the  improvement  ceases 
under  the  use  of  electricity  Mr.  James  recommends  the  discontinu- 
ance of  the  agent  for  a  week  or  two.  The  progress  in  treatment  by 
electricity  is  by  this  interim  of  rest  rendered  again  susceptible  to 
improvement,  and  more  especially  after  a  strengthening  regimen, 
with  tonics  and  friction,  carefully  guarding  the  patient  from  ex- 
posure to  cold. 

M.  Bermond,  of  Bordeaux,  relates  a  case  of  hemiplegia,  follow- 


Electricity  as  a  Therapeutic  A  gen t.  139 

ing  apoplexy,  in  a  lady,  aged  twenty- six,  in  which  the  Leyden  jar 
was  successfully  employed.  After  three  months'  medical  treatment 
the  hemiplegia  remained  nearly  complete.  The  memory  was  slightly 
impaired,  and  there  was  unusual  nervous  irritability.  At  the  first 
sitting,  shocks  from  the  jar  were  passed  from  the  hand  to  the  foot 
of  the  affected  side.  After  fifty  moderate  shocks  considerable  im- 
provement manifested  itself.  After  the  fourth  sitting,  four  days 
later,  the  patient  took  some  steps.  At  the  tenth  sitting,  seven  weeks 
from  the  commencement,  the  patient  walked  to  the  office  of  M. 
Bermond.  After  the  eleventh  application,  a  week  later,  the  cure 
might  be  considered  as  almost  complete.  The  shocks  were  increased 
in  number  toward  the  close,  and  directed,  at  times,  to  a  single  limb 
or  to  the  tongue.     This  was  a  case  of  unusual  discouragement. 

M.  Bermond  relates  another  case,  even  more  discouraging  as  to 
affording  relief  of  a  lady,  aged  fifty-six,  who,  when  in  full  health, 
was  attacked  with  apoplexy,  resulting  in  hemiplegia,  and  which 
remained  after  relief  from  the  apopletic  seizure.  Speech  was  diflB- 
cult,  the  saliva  constantly  flowing  from  the  corners  of  the  mouth. 
Taste  and  hearing  were  both  affected,  deglutition  difficult,  the  blad- 
der distended,  constipation  at  first  obstinate,  and  cramps  in  the 
paralyzed  limbs  frequent  for  the  first  fifteen  days.  (Edema  at  length 
appeared  throughout  the  left  side.  After  a  month,  a  slight  improve- 
ment had  taken  place  in  other  respects,  when  electricity  was  applied 
by  M.  Bermond.  After  the  first  application  the  patient  was  able  to 
stand,  and  even  to  stoop  slightly  and  recover  the  erect  position.  On 
the  following  day,  the  features  had  become  more  regular,  the  hear- 
ing improved,  the  oedema  diminished,  and  an  abundant  perspiration 
had  ensued  upon  the  limbs  of  the  left  side.  The  application  was 
then  repeated.  The  circulation  increased  in  force,  and  on  the  third 
application,  which  took  place  two  days  later,  the  pulse  was  greatly 
increased  and  plethoric  symptoms  induced,  which  yielded  readily  to 
treatment.  After  twentv  applications,  the  patient  had  essentially 
recovered.* 

We  have  related  this  case  as  a  representative  condition  of  a  num- 
ber of  cases  that  we  have  treated,  where  the  patients  were  of  full 
habit  and  laboring  under  paralytic  seizures.  The  electric  treatment 
invariably  increased  the  circulation  of  the  blood  to  a  plethoric  con- 
dition, that  in  many  instances  hydragogue  cathartics  afforded  no 

*Bul.  Med.  de  Bordeaux. 


140  Orthop^bia 

relief;  but  requii'ed  for  their  relief,  venesection.  This  plethoric 
disposition  is  a  most  favorable  indication  of  recovery,  indicative  of 
an  obscure  internal  congestion  relieved  by  the  diffusive  effect  of 
electricity  and  developed  in  the  superficial  circulation.  Such  cases 
advance  to  recovery  upon  the  reduction  of  their  plethoric  condi- 
tion. In  a  majority  of  these  cases,  hydragogue  cathartics  are  all 
sufficient  as  derivatives  that  afford  relief.  Our  treatment  is  the 
application  of  light  shocks  passed  from  the  upper  cervical  vertebraa 
to  the  extremities  of  the  limbs  —  the  patient  being  insulated, — and, 
at  the  same  time,  drawing  off  the  electricity  from  the  extremities 
with  metallic  points ;  carefully  observing  the  influence  upon  the 
patient,  as  we  have  observed  in  some  patients  a  decided  indication 
of  prostration  whilst  under  the  direct  influence  of  the  electricity. 
The  veins  become  greatly  dilated  in  the  feet  and  hands,  apparently 
lessening  the  circulation  about  the  vital  organs  —  an  effect  not  pro- 
ducible by  dynamic  electricity  to  the  same  extent.  This  equaliza- 
tion of  the  circulation  of  the  blood  by  diversion  from  congested 
tissues  in  delicate  patients,  supersedes  depletion,  and  thus  avoids  an 
expenditure  of  vital  force,  such  as  made  in  blood-letting,  evacuants, 
and  starving  the  patient. 

Eor  the  relief  of  sciatica,  static  electricity  has  been  a  most  potent 
remedy.  Dr.  Marchant,  of  Hemsvvorth,  relates  his  own  case,  in 
which  the  pain  extended  from  the  sacrum  to  the  hip.  Leeches, 
blisters,  opium  and  other  remedies  were  employed  with  some  ameli- 
oration of  the  symptoms,  but  not  beyond  the  point  at  which  a 
crutch  could  be  dispensed  with.  Sparks  were  then  drawn,  night 
and  morning,  for  fifteen  minutes  from  the  affected  parts,  which 
treatment  was  followed,  in  a  week,  by  material  improvement,  and, 
in  three  weeks,  an  entire  cure.  It  is  stated  in  the  reports  of  Gruy's 
hospital  that  relief  was  often  obtained  in  sciatica  by  drawing  sparks 
from  the  seat  of  pain. 

We  have  applied  static  electricity  for  the  cure  of  sciatica  by  insu- 
lation, attracting  sparks,  and  drawing  off  the  electricity  with  fine 
metallic  points,  and,  by  light  shocks ;  affording  relief,  in  many  cases, 
without  auxiliary  aid.  But  we  have  usually  afforded  the  most 
immediate  relief  from  the  arsenite  of  potassa  as  an  auxiliary  to 
the  efficiency  of  electricity.  The  patient  being  insulated,  and  a 
silent  current  drawn  by  a  single  metallic  point  and  continued  for 
fifteen  minutes  at  a  sitting,  being  repeated  every  day,  usually  affords 
relief.     If  not  we  prescribe  from  five  to  fifteen  drops  of  Fowler's 


ElEGTBICITY  AS  A   THERAPEUTIG  AGENT.  141 

solution  of  arsenic,  to  be  taken  at  three  intervals  during  the 
twenty-four  hours  from  day  to  day.  If  then  not  relieved,  we  dimin- 
ish the  interval  and  give,  every  four  hours,  until  decided  nausea  is 
induced.  The  following  prescription  often  affords  relief  independ- 
ent of  other  remedies : 

^ .  Soda  bicarb.  3  i. 

Pulv.    oj)ii. 

"       ipecac,  aa.    grs.  i. 
^. 
Ft.  cht.   no.  X. 
One  to  be  taken  every  fourth  hour. 

This  relieves  the  kidneys,  as  they  are  most  commonly  in  an  abnor- 
mal functional  condition  in  seizures  of  sciatica.  Oxalate  of  lime 
may  be  detected  by  the  microscope  in  nearly  every  case  as  in  cases 
of  dyspepsia,  and  so  stated  by  Dr.  Golding  Bird,  and  described  as 
oxaluria,  associated  with  dyspepsia.  For  the  relief  of  this  he  pre- 
scribes nitro-muriatic  acid  —  quite  a  successful  treatment.  The 
soda,  opium,  and  ipecac  have  served  the  purpose  equally  as  well,  and, 
we  believe,  have  given  a  more  decided  and  permanent  relief. 

Cliorea  is  one  of  the  ailments  relieved  by  static  electricity.  During 
the  past  thirty  years  we  have  cured  many  cases  of  patients,  aged 
from  twelve  to  twenty  years,  and  nearly  all  girls.  In  Guy's  Hospi- 
tal, Dr.  Hughes  reports  a  digest  of  one  hundred  cases,  fourteen  of 
which  were  treated  by  electricity.  Of  these,  some  were  of  long  dura- 
tion and  severe  form.     Nine  were  cured.     The  Doctor  remarks : 

"  The  effects  of  electricity  in  chorea  are  sometimes  very  remarka- 
ble. On  some  occasions  I  have  known  it  to  effect  a  cure  after  a 
great  variety  of, other  remedies  had  been  tried,  for  weeks  and  months 
in  vain.  The  change  has  not  been  more  beneficial  than  rapid.  In 
the  course  of  a  week  or  ten  days,  the  entire  aspect  of  the  patient 
has  been  changed.  When  electricity  acts  beneficially  in  chorea  it 
produces  its  effects  more  rapidly  than  any  other  remedy  with  which 
I  am  acquainted." 

A  girl,  aged  sixteen,  had  chorea,  with  deranged  catamenia.  Aspect, 
fatuitas,  occasionally  wild,  and  almost  maniacal.  Disease  of  twelve 
months'  standing.  Sparks  from  the  spine,  and  shocks  through  the 
pelvis  for  a  month,  terminating  in  a  perfect  cure. 

Dr.  Golding  Bird  furnishes  a  table  of  thirty  cases  treated  by  static 
electricity,  in  one  of  which  was  organic  diseases  ot  the  spinal  cord 


142  Orthop^bia. 

and  failed  in  being  relieved;  one  left  from  alarm;  five  were  much 
relieved,  and  twenty-three  cured.  A  few  of  these,  he  states,  we.re 
under  contemporaneous  treatment  of  medicine,  mostly  mild  purga- 
tives. In  many  of  them,  every  variety  of  treatment  had  been 
exhausted  before  having  resource  to  electricity.  The  treatment  was 
confined  to  machine  electricity  (t.  e.,  static  electricity)  drawn  by 
sparks  from  the  spinal  column.  The  application  was  made  every 
other  day,  for  five  minutes,  or,  until  a  papular  eruption  appeared. 

In  all  cases  of  chorea  that  we  have  treated,  we  have  given  very 
decided  purgatives  to  relieve  the  alimentary  canal  of  any  irritating 
foecal  accumulation  that  might  exist,  and  bismuth  and  quinine  as  a 
tonic;  believing  the  system  to  be  in  an  asthenic  condition.  Con- 
joining these  medicines  we  make  use  of  the  efficiency  of  static  elec- 
tricity in  the  form  of  drawing  sparks  from  insulated  patients,  as 
described  in  the  previous  pages. 

Amenorrlicea.  By  means  of  static  electricity,  this  condition  of  the- 
patient  has  been  more  readily  relieved  than  by  any  other  remedy. 
This  has  been  our  experience,  and  agrees  with  Dr.  Bird's  assertions 
in  his  lectures:  '-'In  electricity,"  he  says,  "we  possess  the  only 
really  direct  emmenagogue  which  the  experience  of  our  profession 
has  furnished  us  Avith.  I  do  not  think  I  have  ever  known  it  to 
fail  in  exciting  menstruation  where  the  uterus  was  capable  of  per- 
forming this  function.  The  rule  for  insuring  success  in  the  great 
mass  of  cases  of  amenorrhoea  is  sufficiently  simple.  Improve  the- 
general  health  by  exercise  and  tonics,  remove  the  accumulations  in 
the  bowels  by  appropriate  purgatives,  and  then  a  few  electrical 
shocks,  often  a  single  one  will  be  sufficient  to  produce  menstruation,. 
and  at  once  restore  the  previous  deficient  function."  A  dozen 
shocks  from  the  Leyden  jar  were  usually  passed  through  the  pelvis- 
from  the  sacrum  to  the  pubis,  and  if  the  catamenia  were  not  estab- 
lished in  four  or  five  weeks,  he  discontinued  electrical  treatment^ 
and  renewed  it  after  searching  for  and  removing  the  cause  of  the- 
general  derangement.  A  table  of  twenty-four  cases  was  given  by 
Dr.  Bird,  in  which  there  was  no  relief  in  four,  being  well-marked 
cases  of    chlorosis,  but  a  cure  was  efiected  in  the  remaining  twenty. 

"We  would  here  remark  that  dynamic  electricity  is  very  efficient 
in  the  relief  of  amenorrhcea,  as  well  as  in  many  of  the  ailments 
that  are  readily  relieved  by  static  electricity. 

Tumors  are  ailments  susceptible  to  the  influence  of  both  static 
and  dynamic  electricity.     Vascular  and  erectile  tumors  are  proper 


Electricity  AS  A  Therapeutic  Agent.  143 

subjects  for  galvano  puncture.  In  these  cases  coagulation  has 
been  effected,  and  absorption  stimulated  by  this  means,  also,  the 
absorption  of  scrofulous  tumors.  The  general  remark  may  be  made, 
that  wherever  tumors  or  enlargements  of  any  kind  constitute  the 
original  disease,  or  are  subject  of  direct  treatment,  galvanism  may 
be  resorted  to  with  the  hope  of  increasing  the  vital  action  of  the 
part,  and  especially  of  the  absorbent  system.  The  current  should 
be  passed  through  the  tumor  from  the  surface,  or,  by  electro-punc- 
ture needles. 

Aneurisms  have  been  treated  successfully  by  the  electric  puncture, 
M.  Petrequin,  surgeon-in-chief  of  the  Hotel  Dieu,  of  Lyons,  to 
whom  the  priority  of  this  application  is  generally  accorded,  per- 
formed his  first  experiment  upon  human  blood  immediately  after 
its  extraction.  Blood,  therefore,  seems  to  be  susceptible  of  coagula- 
tion while  its  vitality  lasts.  This  gentleman  communicated  to  the 
French  Academy  the  first  case  of  aneurisim  treated  by  this  method. 
This  was  a  traumatic  aneurism  of  the  temporal  artery  of  the  size 
of  an  almond,  of  a  soft  consistence,  and  slightly  sensible  to  pres- 
sure. Two  fine  needles  of  steel  (gold  or  platinum  should  always  be 
employed)  were  plunged  about  four-fifths  of  an  inch  into  the 
tumor  so  as  to  cross  it  at  right  angles.  A  battery  gradually  increased 
to  fifteen  pairs  was  connected  with  these  for  ten  or  twelve  minutes. 
Considerable  pain  Avas  experienced,  and  the  pulsation  gradually 
ceased  to  the  close  of  the  operation.  In  ten  days  the  tumor  was  in 
process  of  absorption.  Other  cases  were,  soon  after,  similarly  treated, 
one,  an  aneurism  of  the  ophthalmic  artery  and  another  of  the  right 
brachial  artery,  with  decided  success.  It  is  necessary  that  the 
needles  should  terminate  in  the  fluid  blood,  and  not  in  the  coats  of 
the  sac,  to  ensure  a  firm  coagulation. 

Treatment  of  tumors  by  the  Voltaic  pile  is  one  of  the  most 
simple  methods  of  applying  electricity.  Dr.  Maurice  H.  Collis,  sur- 
geon to  the  Meath  Hospital,  and  County  Infirmary,*  states  his  ex- 
perience and  mode  of  applying  it,  with  jDertinent  remarks: 

"It  occurred  to  me,  however,  that  something  could  be  done  to- 
ward procuring  the  absorption  of  tumors,  or,  perhaps,  toward  check- 
ing their  growth,  by  using  galvanism  simply  as  a  stimulant.  A 
slight,  occasional  current,  by  its  stimulus,  will  develop  a  wasted 
muscle;  while  the  continuous  use  of  the  same  current  will,  by  over- 

*Brit.  Med.  Journal,  December  7,  1867. 


144  Obthop^bia. 

SLimulation,  cause  it  again  to  waste.  I,  therefore,  sought  to  apply 
this  principle  to  tumors  of  various  kinds,  and  to  cause  them  to 
waste  by  keeping  up  a  constant  flow  of  electricity  through  them. 

"  For  reasons,  which  I  need  not  enter  upon,  I  tried  various  forms 
Df  batteries,  and,  finally,  returned  to  the  simple  voltaic  pile  com- 
posed of  a  dozen  or  more  couples  of  zinc  and  copper,  an  inch  and  a 
half  square,  or  of  small  cylinders,  or,  plates  of  wood  covered  with 
felt  and  wrapped  around  with  zinc  and  copper  wire.  These  simple 
batteries  were  excited  by  salt  water  or  by  sulphuric  acid  in  the  pro- 
portion of  one  part  of  acid  to  twenty  of  water. 

"  The  mode  of  application  was  as  follows :  The  tumor  was  cov- 
ered with  a  plate  of  zinc,  perforated  zinc,  silver  foil,  copper,  or 
copper  plated  with  silver.  The  positive  pole  was  connected  with 
this  plate,  the  negative  pole  with  a  plate  of  copper  which  was  brought 
into  contact  with  the  skin  of  the  back,  or  other  con  venient  part. 
The  battery,  tied  up  in  a  gutta-percha  paper  or  oiled  silk,  lay  on  a 
table,  or  was  tied  around  the  waist  of  the  patient. 

"■  The  results  were  as  follows : 

"  1.  Complete  removal  of  secondary  cancerous  deposits  from  a 
gland  in  the  neck. 

"  2.  Eapid  absorption  of  inflammatory  deposit  over  and  around 
an  immense  mass  of  strumous  gland. 

"  3.  Slow  removal  of  said  gland. 

''  4.  Immediate  check  to  the  growth  of  a  tumor  composed  of  an 
aggregation  of  strumous  glands. 

"5.  Considerable  cutaneous  and  sub-cutaneous  inflammation  in 
the  same  case  with  softening  and  breaking  up  of  the  diseased 
glands. 

"6.  Decided  absorption  of  inflammatory  efi'usion  around  primary 
scirrhus  of  mammary  region. 

"  7.  Diminution  and  softening  of  a  very  firm  fibrous  growth  at- 
tached to  the  periosteum. 

"  All  these  results,  except  No.  3,  were  obtained  in  from  three  to 
six  days  ;  and  all  the  cases  had  been  previously  submitted  to  a  va- 
riety of  treatment  without  benefit.  Special  results  of  a  peculiar 
nature  were  observed,  as  follows  : 

"  8.  The  zinc  plate  on  the  skin  showed  the  usual  tendency  to  de- 
compose the  skin,  and  produce  ulceration  in  a  few  hours. 

''  9.  Perforated  zinc,  em.ployed  to  obviate  this,  produced phlyctenaa 
and  pustules  in  the  inter  spaces  not  covered  by  it. 


Electricity  as  a  Therapeutic  Agent.  145 

"  10.  Silver,  whether  as  foil  or  plated  on  copper,  produced  redness 
of  the  skin,  but  with  less  rapid  tendency  to  ulceration. 

"11.  Copper  plates  were  comparatively  slow  to  act  on  the  skin  in 
connection  with  the  negative  pole ;  but  the  copper  connected  with 
the  positive  pole,  on  one  occasion,  blistered  the  skin  severely  when 
a  very  strong  battery  was  used. 

"■  For  the  rest,  the  batteries  of  wire  coiled  on  wood  are  much 
lighter  and  more  convenient  in  proportion  to  their  strength.  They 
preserve  their  activity  sufficiently,  and  do  not  wear  out  so  soon  as 
the  voltaic  pile  of  zinc  and  copper  plates.  They  have  the  further 
advantage  that  as  many  or  as  feAV  as  desired  can  be  used  without 
delay  in  arrangement.  I  believe  that  a  very  strong  current,  whether 
as  to  quantity  or  tension,  is  not  required.  A  small  quantity  is  suf- 
ficient to  excite  the  nerves  of  the  blood-vessels ;  and  there  should 
be  just  sufficient  tension  to  ensure  that  the  current  pass  through 
the  part  to  be  acted  on,  and  not  merely  round  by  the  skin.  I  believe 
that,  without  claiming  any  miraculous  power  for  electricity  thus 
applied,  we  have  in  it  an  agent  of  considerable  energy,  and  capable 
of  yielding  results  of  sufficient  value  to  warrant  us  in  resorting  to 
it  more  frequently  than  hitherto." 


MODES  OP  APPLYING  ELECTRICITY. 

The  efficiency  of  electricity  as  a  therapeutic  agent  depends  much 
upon  its  application ;  in  quantity,  intensity  and  local  application  — 
thus  modifying  all  the  various  means  by  which  it  is  obtained.  Elec- 
tricity, when  applied,  should  be  localized  as  much  as  possible.  Dr. 
Duchenne  was  the  first  to  invite  special  attention  to  this  important 
principle  in  its  application,  and  termed  his  method  "Faradization," 
in  honor  of  Faraday,  who  discovered  the  important  phenomena  of 
induction.  There  are  two  modes  of  applying  electricity  as  an 
excitant  and  deobstruent :  that  of  direct  and  indirect.  By  concen- 
trating the  excitation  directly  on  the  muscle,  we  have  the  direct 
application,  and  if  through  the  nerve,  or  branch,  supplying  the  mus- 
cle, the  indirect  application.  This  requires  an  exact  knowledge  of 
the  anatomy  of  the  nerves  and  muscles.  In  the  arm,  the  electric 
power  can  be  limited  to  the  median  nerve  on  the  inner  and  inferior 
third  of  the  humerus,  to  the  ulnar  nerve,  on  the  interval  between 


146  Or  thopjedia. 

the  olecranon  and  the  internal  condyle.  The  radial  nerve  is  acceS' 
Bible  at  the  junction  of  the  two  upper  thirds  of  the  humerus  with  its 
lower  third ;  the  musculo-cutaneous  in  the  axilla.  On  the  thigh, 
indirect  is  easier.  The  crural  nerve  is  to  be  found  in  the  groin 
outside  of  the  femoral  artery ;  the  two  popliteal  nerves,  in  the  pop- 
liteal space.  The  sciatic  nerve  is  only  accessible  to  electricity  on 
its  origin  in  the  pelvis,  through  the  posterior  wall  of  the  rectum. 
On  the  face,  the  trunk  of  the  seventh  pair,  covered  by  the  parotid 
gland,  is  inaccessible  to  electricity,  whatever  may  be  the  intensity  of 
the  current ;  but,  it  can  be  reached  where  it  passes  out  of  the  stylo- 
mastoid foramen ;  here  a  hand  director  is  to  be  placed  in  the  external 
opening  of  the  ear;  in  this  point,  the  nervous  trunk  is  separated 
from  the  excitor  by  only  a  small  space.  Its  branches  may  be  excited 
at  the  point  where  they  emerge  from  the  parotid  gland.  Contrac- 
tion of  the  muscles,  being  under  control  of  these  branches,  is  the 
certain  signal  of  their  electric  excitation.  In  the  supra-clavicular 
region,  the  director  placed  immediately  over  the  clavicle  acts  on  the 
brachial  plexus.  On  the  summit  of  the  supra-clavicular  trough, 
they  are  in  connection  with  the  external  branch  of  the  eleventh 
pair.  This  is  the  respiratory  nerve  of  Bell,  and  the  most  excitable 
of  all  the  nerves  of  the  human  body.  The  lower  half  of  the  sterno- 
cleido-mastoid  and  trapezius  is  excitable  to  only  a  small  extent. 
Bat,  when  a  very  feeble  current  is  directed  on  the  upper  half  of  the 
stern o-cleido-mastoid,  or,  on  the  external  border  of  the  upper  half 
of  the  trapezius,  —  a  current,  indeed,  which  would  not  be  expected 
to  produce  any  movement  in  the  muscles  at  all  —  the  head  is 
strangely  inclined  to  the  side  acted  upon,  and  the  shoulder  drawn 
up  by  a  violent  and  sudden  movement. 

The  muscles,  like  the  nerves,  do  not  all  possess  the  same  degree 
of  excitability.  Some  muscles  are  so  extremely  sensitive  that  the 
excitation  can  scarcely  be  induced.  Muscular  sensitiveness  is  most 
active  in  the  muscles  of  the  face,  due  to  the  ramifications  of  the 
fifth  pair  which  excite  these  muscles.  It  is  important  to  always 
avoid  the  points  corresponding  to  the  infra-orbitse  and  sub-mental 
nerves,  the  excitation  of  which  gives  a  very  painful  sensation.  The 
most  excitable  muscles  of  the  face  are  the  frontal  muscles  and  the 
orbicularis  palpebrarum ;  the  least  so,  the  buccinator  and  the  mas- 
seter  ;  of  the  neck,  the  platysma  myoides  is  just  as  excitable  as  the 
upper  half  of  the  sterno-cleido-mastoid  and  the  external  border  of 
the  upper  half  of  the  trapezius.     The  most  excitable  muscles  of  the 


BLECTRICITY  AS  A   THERAPEUTIC  AGENT.  147 

trunk  are  the  pectorales  major  and  the  muscles  of  the  fossa  infra- 
spinatus —  chiefly  the  rhomboidal ;  then  follows  the  deltoid,  and 
the  muscles  of  the  arm.  The  anterior  are  much  more  excitable  than 
the  posterior  muscles  of  the  extremities.  The  most  excitable  muscle 
of  the  leg  is  the  tensor  vaginae  femoris. 

Galvanism  has  been  applied  in  the  form  of  plates  known  as  Mans- 
ford's  plates.  In  asthma,  a  small  blister,  the  size  of  a  dollar,  being 
placed  on  the  neck  over  the  course  of  the  phrenic  and  pneumogastric 
nerves,  and  another,  on  the  side  in  the  region  of  the  diaphragm,  and 
one  metal  placed  over  the  vesicated  surface  on  the  neck  and  another 
over  that  on  the  side, — connection  being  made  by  means  of  wire — the 
normal  nervous  influence  is,  in  this  way,  induced  and  is  often  signally 
beneficial.  By  a  somewhat  similar  procedure  with  galvanic  plates, 
ulcers  in  a  toi'pid  condition  have  been  greatly  improved,  tending  to 
a  healing  condition.  There  are  various  modes  of  obtaining  galvanic 
influence ;  as  galvanic  chains,  such  as  that  of  the  Pulvermacher's 
hydro-electric  chain  battery — a  modification  of  the  voltaic  pile, 
capable  of  being  employed  topically.  The  galvanic  influence  upon 
muscular  tissues  is  greater  than  that  of  the  faradic,  often  producing 
muscular  contractions  in  cases  where  the  faradic  fails,  and  exerts  a 
more  decided  chemical  action,  even  to  that  of  an  actual  cautery — • 
known  as  the  galvano-cautery.  It  consists  of  a  continuous  current, 
is  developed  by  chemical  decomposition  and  is  characterized  as  "low 
intensity  "  so  far  as  regards  its  action  upon  nerves  and  muscles,  but 
of  most  extensive  quantity  and  increase  of  temperature,  termed 
"thermic  results,"  not  equaled  by  other  means  of  accumulating 
electricity. 

The  continuous  current  is  accomplished  by  introducing  a  part  or 
the  whole  of  the  body  of  a  patient  into  and  making  it  a  part  of  the 
circle  of  the  battery  and  then  passing  the  current  through  it.  This 
will  relieve  spasms  of  a  certain  kind,  and  certain  kinds  of  pain.  In 
some  cases  this  is  accomplished  in  a  few  moments,  in  others  a  repeti- 
tion at  intervals  will  be  required.  It  will  also  arrest  tremor  and 
spasms.  There  are  various  modes  of  applying  the  continuous 
current.  To  connect  the  positive  end  of  the  battery  with  a  person's 
left  hand,  and  the  negative  end  with  the  right;  the  current, 
passing  from  the  positive  to  the  negative  pole,  passes  up  the  left  arm 
to  the  trunk  and  down  the  right  arm  to  the  battery  again.  This  is 
termed  the  "inverse  current  application"  when  passing  up  the  arm, 
and  when  passing  down,  the  "  direct."     This  tends  to  two  opposite 


148  ObthopuEdia. 

effects.  The  current  passing  up  the  left  arm  excites  the  irritahilUy 
of  the  muscles  and  nerves,  and  that  passing  down  the  right  arm 
allays  irritability  in  that  arm.  This  serves  well  for  theory,  but  is 
not  sustained  as  of  any  practical  utility.  Pain  is  as  readily  relieved 
by  the  current  in  one  direction  as  the  other,  and  the  same  is  the 
case  in  the  treatment  of  spasm,  whether  clonic  or  tonic,  or  merely 
tremor. 

The  continuous  current  is  in  degree  painful  in  ratio  to  its  strength 
even  to  that  of  being  unbearable,  or  so  mild  as  not  to  be  unpleasant. 

The  interrupted  current  is  made  in  various  ways.  By  taking  two 
wet  sponges  attached  by  wires  to  the  two  ends  of  the  battery,  and 
placing  one  on  the  upper  part  of  the  limb,  and  interrupting  the 
current  by  occasionally  lifting  it,  and  the  other  sponge  at  a  distance 
from  or  under  the  limb,  makes  a  break  in  the  current  and  constitutes 
an  interrupted  current.  Or,  any  more  complete  means  as  that  of 
apparatus  so  constructed  as  to  break  the  current  instanced  in  one 
of  the  ordinary  interrupters.  In  the  interrupted  battery  current, 
the  direct  application  produces  a  more  obvious  effect  iipon  the 
muscles  in  the  way  of  contraction  than  the  inverse  or  indirect,  and 
is  worthy  of  note  when  applied  for  the  purposes  of  diagnosis  or 
treatment.  The  various  terms  applied,  such  as  "Faradization," 
"  induced  electricity,"  "  magneto-electric,"  "  voltao-magnetic," 
^'voltao-dynamic,"  are  all  of  which  Faraday  was  the  great  exponent. 
It  is  electricity  of  very  high  tension  and  differs  from  the  magetic  cur- 
rent in  the  particular  of  not  eliminating  the  sensation  of  heat,  but, 
under  ordinary  circumstances,  produces  marked  contraction  of  the 
muscles  and  a  more  painful  action  on  the  nerves  of  motion  and 
sensation.  It  exists  only  at  the  moment  of  making  or  breaking  the 
galvanic  current.  There  are  two  terms  commonly  used  in  regard, 
to  different  batteries  —  "primary"  or  "secondary."  This  is  for 
chemical  purposes.  The  difference  is  said  to  be  that  the  primary 
will  have  a  more  distinct  action  upon  one  set  of  nerves,  and  the 
secondary  upon  another.  But  the  most  marked  physiological 
difference  between  them  is  that  the  secondary  is  of  greater  in- 
tensity than  the  primary,  and  will  sometimes  proceed  more  deeply 
into  the  parts  intended  to  be  affected.  The  word  primary  is  not 
intended  to  signify  a  primary  current  in  the  sense  of  being  a  bat- 
tery current;  it  is,  essentially,  an  induced  current.  The  other  is  an 
induction  from  an  induction,  and  is  secondarily  induced,  the  clinical 
difference  between  them  being,  mainly,    the   degree   of    intensity. 


Blecteicity  as  a  Therapeutic  Agent.  149 

For  confirmation,  see  London  Lancet,  March  5,  1870,  p.  331 :   a 
paper  by  Dr.  J.  E.  Eeynolds,  F.  R.  S. 

In  our  experience,  as  well  as  in  that  of  others,  it  has  been  dis- 
covered that  electricity  is  only  of  utility  in  the  treatment  of  a  cer- 
tain class  of  ailments,  and  requires  modifications  under  varied 
conditions  of  the  cases  susceptible  of  relief  from  its  skilful  applica- 
tion. The  first  apparent  difficulty  that  presents,  is  the  varying 
sensibility  peculiar  to  each  individual  in  a  normal  condition,  and 
which  is  apt  to  confuse  the  practitioner  in  his  diagnosis.  This  can 
only  be  determined  by  close  observation  and  the  avoidance  of  hasty 
conclusions.  If  simply  a  failure  to  relieve,  in  some  cases,  should 
ensue,  no  great  injury  could  result,  but  there  is  great  liability  to 
inflict  injury  in  others,  productive  of  the  most  serious  consequences 
to  the  patient  and  the  reputation  of  the  practitioner,  as  the  mis- 
take made  in  the  application  of  electricity  is  usually  very  apparent. 

Sensibility  is  mainly  dependent  upon  the  nervous  condition  of 
the.  patient,  being  more  or  less  exaggerated  by  mental  impression,, 
but,  in  some  cases,  one  limb  is  more  sensitive  than  its  fellow,  and 
most  apparent  in  sensibility  of  its  muscles  to  electric  influence. 
This  is  valuable  as  a  diagnosis  of  the  lesion  in  that  limb. 

Partial  insensibility  is  most  readily  detected  by  loss  of  tactile- 
sense  of  the  power  of  appreciating  heat  or  cold,  and  presents  in 
cases  without  paralysis,  and  may  exist  as  a  symptom  of  cerebral 
disease. 

Increased  cuticular  sensibility,  hypersesthesia,  presents  in  cases  of 
paraplegia  from  lesion  in  the  spinal  column,  even  before  the  spinal 
projection  has  taken  place,  and  is  a  diagnostic  symptom.  A  change 
in  the  central  nervous  system  is  often  indicated  by  painful  muscular 
contraction,  general  or  local,  and,  in  some  cases,  is  attended  with 
increased  cutaneous  sensibility,  often  by  neuralgia  and  false  impres- 
sions. In  these  conditions,  the  sensibility  is  augmented  by  electric 
influence  to  a  greater  degree  than  in  the  normal  condition,  and 
can,  in  slight  cases,  be  determined  by  comparison  when  limited  to- 
local  parts. 

The  sensibility  of  muscles  is  usually  diminished  when  their  con- 
tractility is  reduced,  and  in  direct  proportion  to  that  reduction  — 
as  in  lead  paralysis. 

Electricity  can  be  made  available  to  the  arresting  of  morbid  sensi- 
bility in  nerve  or  muscle,  or,  to  excite  to  activity  a  dormant  nerve 
or  muscle.     It  is  a  force  to  relieve  paralysis,  restore  loss  of  sensa- 


150  Orthopjedia. 

tion,  or  of  contractility  in  a  muscle,  or,  to  diminish  over  action  or 
spasm  —  whether  tonic  or  clonic  —  by  restoring  nerve  or  muscle  to 
a  normal  condition.  It  will  relieve  a  peculiar  under-tone  of  the 
muscles  in  a  limb  in  which  the  movements  are  made  by  a  limited 
force  —  the  muscles  being  lax  in  texture,  but  equal  in  size  to  its 
fellow.  To  this  we  have  an  opposite  condition  —  hardness  of  mus- 
cles, not  to  actual  rigidity,  and,  in  some  cases,  actual  rigidity,  in 
which  it  is  difficult  to  flex  or  extend  the  arm  or  leg ;  in  others,  a 
tremulousness  of  a  muscle;  and,  lastly,  clonic  spasm  apparent  in 
interrupted  movements  of  the  limb  —  all  subject  to  relief  from  elec- 
tricity. 

The  circulatory  system  is  quite  as  subject  to  the  favorable 
influence  of  electricity.  The  influence  upon  the  muscular  fibre  in 
the  walls  of  the  blood  vessels  is  the  same  as  upon  other  muscular 
tissues  ;  the  capillary  vessels  being  dilated,  as  they  are  in  paralyzed 
limbs,  and  as  indicated  by  the  purplish  color,  and  coldness  of  the 
limbs.  To  the  relief  of  this  condition,  electricity  can  be  made 
available.  It  tends  to  induce  contraction  of  the  vessels  by  simply 
acting  on  the  cutaneous  tissue,  and  can  be  so  limited,  and  quite 
as  subject  to  an  apparent  relief  in  the  contracted  condition  of  the 
blood  vessels  as  in  that  of  its  contractile  fibres. 

The  accomplishment  of  other  desirable  intentions  requires  knowl- 
edge and  experience  in  the  use  of  electricity  as  a  therapeutic  agent, 
and  some  general  ideas  on  the  subject  may  here  be  given. 

An  over-excited  nerve,  muscle  or  blood-vessel  may  be  subdued  by 
the  continuous  galvanic  current,  and,  as  before  stated,  from  the 
shoulder  to  the  hand,  or  from  the  body  outward,  not  so  strong  as 
to  give  pain,  and  applied  in  the  course  of  a  principal  nerve.  Static 
electricity  affords  equal  relief  by  insulating  the  patient  and  charg- 
ing them  largely  with  electricity,  then  drawing  it  oif  with  a  metal- 
lic point  attached  to  a  conductor  passing  to  the  earth.  Faradiza- 
tion may  be  employed  for  this  purpose  in  such  cases  as  that  ot 
spasmodic  torticollis.  Eelief  may  be  afforded  by  passing  through 
the  sterno-cleido-mastoid  muscle  a  weak,  rapidly  interrupted  cur- 
rent, or  by  faradizing  the  antagonist  muscle.  This,  also,  applies  to 
the  leg  or  arm  when  in  like  condition. 

In  paralysis  from  cerebral  lesion,  electricity  is  inadmissible  in  its 
early  stage  or  at  any  time  when  there  is  pain  or  congestive  symptoms 
in  the  head.  In  progressive  paralysis  from  whatever  cause,  with  no 
pain  or  feeling  in  the  head,  electricity  may  be  used  freely  and  often, 


Electricity  AS  A  Tmebapeutig  Agent.  151 

to  great  relief  to  the  patient.  There  are  certain  conditions  of  para- 
lyzed limbs  in  which  electricity  affords  little  or  no  relief.  If,  on 
applying  the  current,  a  ready  response  of  the  limb  is  found  and 
nearly  as  strong  as  in  the  sound  limb,  very  little  relief  will  be  afforded 
other  than  improving  the  circulation  in  the  limb,  no  matter  how 
long  it  may  be  applied  or  how  complete  the  paralysis  may  be.  All 
the  benefit  that  can  be  obtained  from  the  use  of  dynamic  electricity 
is  in  exciting  contractility  in  the  muscular  fibre,  and  this  will  often 
cure  the  patient;  but  it  must  be  borne  in  mind  that  the  contractile 
energy  of  muscular  fibre  is  not  the  moving  power  of  the  limb. 

As  to  the  inverse  or  direct  interrupted  current  in  the  application 
of  electricity  for  the  relief  of  paralysis,  there  is  little  or  no  difference. 
It  is  only  when  the  continuous  current  is  applied  that  the  physio- 
logical effect  on  the  nerve  differs ;  the  current  downward  or  out- 
ward from  the  body  diminishes  irritability,  and  the  current  upward 
increases  it;  the  current  downward  acts  more  strongly  than  it  does 
upward.  This  is  of  some  importance  in  relation  to  the  influence  of 
the  electric  current. 

Much  precaution  must  be  used  in  the  application  of  electricity  as 
a  therapeutic  agent.  A  stronger  or  milder  current  must  be  used 
according  to  the  direction  in  which  the  electricity  is  to  be  sent,  and, 
in  all  applications,  care  must  be  taken  never  to  use  such  force  as  to 
give  pain.  It  is  only  necessary  to  produce  contraction,  and  this  is 
essential  to  the  accomplishment  of  any  beneficial  influence.  To  be 
enabled  to  so  limit  the  current  to  the  condition  of  the  patient,  it  is 
necessary  to  become  familiar  with  their  sensibility.  As  before  stated 
they  vary  greatly  in  this  particular,  or  in  their  peculiarity  of  consti- 
tution. To  give  pain  from  the  application  of  electricity  is  to  injure 
the  patient,  and  should,  by  all  means,  be  avoided,  if  not  in  the  first 
of  the  application,  it  should  be  so  modified  as  to  terminate  pleas- 
antly, if  possible.  The  application  to  a  paralyzed  limb  to  the  degree 
of  inducing  a  state  of  cramp  is  a  most  pernicious  proceeding. 

The  duration  of  the  application  is  another  important  consideration. 
It  is  possible  to  exhaust  the  vitality  of  the  muscle,  and  there  is  a 
very  great  danger  of  doing  so.  The  safer  plan  is  to  apply  the  elec- 
tricity only  for  a  few  moments,  at  first,  in  order  to  test  the  sensi- 
bility of  the  patient,  and  repeat  the  operation  only  every  other  day 
— even  less  frequent  when  not  much  improvement  is  made.  When 
much  inconvenience  or  discomfort  is  produced  it  is  better  to  discon- 
tinue  its  use  for  a  time,  and  then   return  to  it  from  time  to  time, 


152  Orteof^dia. 

until  the  patient  can  endure  it  without  unpleasant  feelings.  When 
pain  in  the  head,  disposition  to  faint,  or  discomfort  about  the  epigas- 
trium are  noticed,  these  indications  are  carefully  to  be  regarded  as 
dangerous  symptoms  when  under  the  exciting  influence  of  electricity. 
When  insulated,  and  charged  with  static  electricity,  and  a  continu- 
ous current  drawn  by  a  metallic  point  from  the  patient,  no  ill  effects 
will  follow  syncope,  but,  in  many  cases,  much  benefit  in  inflamma- 
tory conditions. 

It  is  a  well  determined  fact  that  abnormal  conditions  of  the  cuti- 
cle, nerve,  or  muscle,  the  result  of  cerebral  lesion,  are  not  relieved 
to  any  appreciable  extent  by  electrical  influence,  and  its  application 
is  often  attended  with  serious  consequences.  Hence  the  necessity 
of  a  careful  diagnosis ;  as  we  have  motor  paralysis  and  anaesthesia 
of  a  limb  or  some  part  of  the  body  from  impairment  of  the  brain. 
Spinal  lesion  tends  to  similar  conditions,  and  for  this  electricity  is 
the  most  reliable  therapeutic  agent  in  our  possession.  We  have  a 
certain  condition  of  patients,  commonly  considered  to  be  given  to 
hysterical  affections  —  marked  ansesthesia,  in  different  parts  of  the 
body  and  limbs  —  and,  as  there  exists  a  certain  relative  influence 
between  the  control  of  motive  power  and  sensation,  there  is  an  op- 
posite inability  to  control  the  movement  of  the  limbs,  amounting, 
in  many  cases,  to  an  inability  to  use  them.  In  these  cases,  the 
defective  sensation  in  the  cuticle  is  most  at  fault  in  the  incipient 
stage  of  the  ailment.  The  muscles  become  impaired  in  tone  because 
the  patient,  being  indisposed  to  exercise  them  on  account  of  their 
awkward  appearance,  fails  to  do  so ;  and  this,  in  some  instances, 
causes  him  to  become  led-ridden,  as  it  is  commonly  designated, 
from  his  refusal  to  leave  his  bed  or  chair. 

Static  electricity  is  the  most  reliable  remedy  for  relieving  the 
patient  from  his  dependent  condition.  The  patient  being  insulated, 
the  electric  rubefacient  should  be  applied  to  the  uonsensitive  skm, 
with  slow  movement  for  about  three  minutes,  and  this  treatment 
repeated  every  other  day.  We  have  seen  patients,  who  have  been 
confined  to  their  rooms  for  a  year  or  more,  enabled,  after  a  second 
or  third  sitting,  to  make  a  successful  effort  at  walking.  In  cases 
where  the  muscles  have  become  deficient  in  excitability  from 
long-continued  inaction,  the  metallic  coated  glass  tube  affords  a 
sufficient  concussion  to  arouse  the  dormant  energy  of  the  muscles; 
ten  or  twenty  shocks  at  a  sitting,  in  the  direction  from  the  origin  to 


Electricity  as  a  Therapeutic  Agent.  153 

the  insertion  of  the  muscles,  the  patient  being  encouraged  at  the 
same  time  to  make  an  effort  to  move  his  limbs. 

In  cases  of  '■'essential  paralysis,"  or  what  we  understand  to  be 
spinal  paralysis  of  children,  they  are  to  be  determined  by  the  degree 
of  irritability  of  the  muscles  as  to  their  being  susceptible  to  improve- 
ment from  electrical  influence  Avhen  in  the  incipient  stage  ;  that  is, 
in  a  week  or  two  after  the  seizure,  as,  in  some  cases,  the  little 
patient  recovers  from  a  complete  prostration  of  all  the  limbs  to 
that  of  an  arm,  or  arm  and  leg,  that  may  continue  paralyzed.  In 
very  rare  cases,  the  irritability  is  so  much  impaired  as  to  refuse  to 
respond  to  the  electric  current  or  spark,  whicli  should  always  be 
cautiously  applied  as  a  means  of  diagnosis.  Electricity,  we  consider, 
in- such  cases,  injures  in  degree  to  its  continued  use.  These  cases 
do  recover,  in  time,  to  a  degree  of  sensibility  to  the  electric  influ- 
ence, when,  with  great  deliberation  in  its  use,  it  becomes  an  efficient 
auxiliary  agent  conjoined  with  means  of  warmth,  manipulation, 
voluntary  efforts  at  exercise,  and  the  retention  of  the  limb  in  nor- 
mal position. 

Cases  of  several  years'  standing  may  be  made  susceptible  of  much 
relief  from  the  careful  application  of  electricity,  either  static  or 
dynamic  ;  one  proving  effectual  after  the  other  has  failed.  But  in 
no  instance  is  electricity  admissible  in  treatment  when  persistent 
contraction  has  taken  place.  The  limbs  must  be  restored  to  normal 
form  before  electricity  can  be  made  available  to  the  restoration  of 
muscular  power ;  as  the  effect  is  to  confirm  the  contractile  tendency 
of  the  already  contracted  muscle  or  muscles  —  that  is,  when  normal 
position  cannot  be  restored  by  gradual  effort  of  the  hands.  In  many 
cases,  only  one  set  of  muscles  are  paralyzed,  and  the  equilibrium  of 
force  impaired,  and  in  many  other  cases  there  is  much  aberration 
from  normal  form  that  can  be  readily  overcome  by  the  hands. 
Suitable  apparatus  should  then  be  applied  to  sustain  the  tempora- 
rily restored  condition  of  the  limb,  and  the  electric  influence  local- 
ized as  much  as  possible  upon  the  paralyzed  muscles.  That  its  influ- 
ence can  be  thus  limited  is  not  in  accordance  with  our  experience. 
We  have  treated  many  cases  of  persistent  contraction,  after  faradi- 
zation in  the  hands  of  experienced  practitioners  had  been  employed 
for  months,  with  no  other  result  than  an  increase  of  the  deformity. 

Restoration  to  normal  form  being  first  accomplished,  then  elec- 
tricity serves  an  admirable  purpose  in  restoring  power  to  the  para- 
lyzed limbs ;  the  influence  on  the  sound  muscles  being  resisted  by 


154  Orthopjebia. 

the  supporting  apparatus.  A  muscle  cannot  maintain  or  obtain 
contractile  force  when  fixedly  or  even  partially  extended.  Faradi- 
zation, skilfully  applied,  is  an  efficient  remedy  in  these  cases,  but 
not  more  so  than  static  electricity  in  the  form  of  sparks  drawn  from 
over  the  paralyzed  muscles,  or  light  shocks  passed  from  the  origin 
to  the  insertion  of  the  muscle  or  muscles,  and  is,  in  reality,  the 
most  localized  form  of  applying  electricity.  For  the  restoration, 
of  nutrition  in  atrophied  muscles  —  that  is,  in  cases  of  several  years, 
standing  —  static  electricity  is  the  most  efficient  in  restoring  activity 
in  the  nutrient  vessels.  Even  where  fatty  degeneration  has  super- 
vened, the  muscle  will  develop  and  increase  in  strength.  The  sar- 
colemma  maintains  its  integrity  in  the  producing  of  muscular  fibre 
quite  equal  with  the  periosteum  in  producing  bone ;  requiring  only 
an  excitant  to  the  normal  functional  condition  that  is  possible  until 
vitality  is  entirely  exhausted. 

There  is  a  form  of  paralysis  affecting  the  vocal  organs  and  the 
voice,  arising  most  commonly  from  an  ansemic  condition  of  the  pa- 
tient and  termed  by  some  writers  hysterical  aphonia.  Static  elec- 
tricity in  the  form  of  sparks,  or,  light  shocks  drawn  from  the  glass 
tube,  will  afford  immediate  relief  and  but  seldom  fails,  when  perse- 
vered in.  The  shock  should  not  be  passed  through  the  larynx,  as 
it  is  very  painful ;  below  or  back  of  the  larynx  is  quite  as  effectual. 

Sudden  and  severe  strains  of  the  arms,  more  especially,  are 
attended  with  severe  pain  and  tingling  sensation  in  the  hand  and 
tips  of  the  fingers,  and,  when  the  pain  ceases,  great  weakness  and 
wasting  of  the  muscles  follows,  particularly  in  the  flexors,  abductors 
and  adductors  of  the  thumb  —  they  becoming  exceedingly  attenu- 
ated. A  similar  condition  results  from  excessive  exposure  of  the 
hand  to  cold.  Static  electricity  in  the  form  of  light  shocks  and 
sparks  usually  affords  relief  and  is  the  only  means  in  these  ailments 
to  be  relied  upon. 

There  is  a  condition  of  progressive  atrophy  induced  from  slight 
injuries  to  the  limbs.  A  case  in  point,  to  illustrate,  is  that  of  a 
young  lady  of  eighteen  years  of  age,  having  a  sick  mother  and 
being  desirous  of  lifting  her,  when  in  bed  to  change  her  position, 
kneeled  on  the  bed-rail  with  one  knee,  when  a  sharp  pain  was 
immediately  felt  in  the  limb.  In  about  a  week  thereafter,  a  severe 
attack  of  seeming  sciatica  followed,  that  was  relieved  by  Fowler's 
solution.  In  about  six  weeks  from  the  time  of  the  injury  to  the 
knee,  she  experienced  weakness  in  the  injured  limb,  and  an  inability 


Electricity  AS  A  Therapeutic  Agent.  155 

to  get  down  the  stairs,  when  we  were  again  consulted.  On  exam- 
ining the  limb  the  muscles  were  found  to  be  very  flaccid  in  texture, 
and  upon  comparing  the  measurement  of  each  thigh  there  was  a 
difference  of  an  inch  and-a-half  in  favor  of  the  sound  limb.  Fara- 
dization was  commenced  with  wet  sponges,  but  failed  to  improve 
the  limb,  which  diminished  in  two  weeks  a  half  inch  —  to  the  great 
alarm  of  the  lady  and  her  friends.  A  change  of  treatment  was 
desired.  Static  electricity,  in  the  form  of  slight  shocks  and  sparks, 
was  applied,  and  measurement  made  of  the  limbs  every  two  or  three 
days,  for  two  weeks,  when  it  was  apparent  that  the  diminution  in 
size  had  not  progressed.  It  was  then  thought  advisable  to  continue 
its  use  twice  a  week.  At  the  expiration  of  three  months  the  limb 
had  increased  in  size  one  inch  and  was,  apparently,  as  strong  as  its 
fellow.  It  continued  to  improve  in  nutrition,  and  in  eighteen 
months  after,  it  Avas  half  an  inch  less  than  the  other  thigh,  but 
apparently  quite  as  strong. 

We  have  had  analogous  cases  from  slight  injuries  below  and 
above  the  knee,  and  also  of  the  arm,  with  like  results  of  progressive 
atrophy  of  the  muscles,  and  that  has  been  relieved  by  static  elec- 
tricity, applied  most  commonly  in  the  form  of  light  shocks  twice  or 
thrice  a  week,  requiring  in  some  cases  many  months  for  an  im- 
provement in  development,  an  increase  of  strength  being  more 
readily  attained,  which  is  remarkable,  because  of  the  deficient  mus- 
cular tissue. 


GENERATORS  OF  GALVANIC  ELECTRICITY. 

Believing  it  to  be  of  special  interest  to  the  medical  practitioner, 
we  present  for  his  consideration  engravings  of  approved  varieties  of 
apparatus  for  generating  dynamic  electricity,  the  following  have 
been  obtained,  with  directions  as  to  their  use,  from  the  Gralvano- 
Faradic  Manufacturing  Company  of  New  York,  to  whom  we  express 
our  grateful  consideration  for  the  favor. 

This  machme  is  most  generally  selected  by  physicians.  It 
has  the  advantage  of  a  cell  in  reserve,  should  the  other  be- 
come exhausted.  Also,  the  strength  of  both  cells  can  be  united 
in  cases  of  suspended  animation,  or  where  great  power  is  re- 
quired . 

The  new  and  elegant  hard    rubber  cells,  though  at  first  appar- 


156 


Orthop^dia. 


Portable  Electro-Magnetic  Machine. 
Fig.  eg. 


ently  costly,  are  ultimately  the  most  economical,  as  there  is  no 
breakage.  They  are  also  preferable  in  other  respects,  especially 
owing  to  their  lightness. 

By  means  of  the  hydrostat  they  are  rendered  portable,  so  that 
they  can  be  carried  around  by  city  or  country  physicians,  charged  and 
ready  for  use,  without  danger  of  spilling  the  battery  fluid. 

Direct  mis  for  use. — To  prepare  the  battery  fluid: 

Take  five  pints  of  cold  water,  add  thereto  eight  ounces  of  bi-chro- 
mate  of  potassa  and  immediately  afterward  seven  fluid  ounces  of 
sulphuric  acid.  Mix  and  dissolve.  Fill  the  battery  cell  with  this 
liquid  two-thirds  full,  which  will  be  about  eleven  ounces.  Connect 
the  battery  or  cell  with  the  machine  by  means  of  the  hooks.  Each 
binding  screw  must  then  be  well  tightened. 

Fasten  the  poll-cords  into  the  arms  of  the  current  charger,  except 
on  the  ISTo.  1,  where  they  are  to  be  connected  with  the  binding  posts 
marked  P  and  N,  which  letters  indicate  the  positive  and  negative 
poles.  To  the  former  the  red  cord  is  attached,  the  green  to  the  latter, 
the  easier  to  designate  the  poles  while  in  use.  When  it  is  not 
especially  intended  to  apply  the  metallic  discs,  sponges  should  be 
fastened  to  the  extreme  points  of  the  handles  of  the  electrodes. 
Previous  to  each  application  these  should  be  thoroughly  moistened  in 
warm  water.  All  being  thus  prepared,  the  machine  can  be  put  into 
action,  by  elevating  the  graduated  hinge-jointed  rod  and  then  lower- 
ing it  down  in  the  battery  cell.  A  knock  on  the  box  will  cause  the 
spring  to  vibrate  and  set  it  going. 


Electricity  AS  A  Therapeutic  Agent.  157 

The  primary  current  (mild)  is  obtained  by  inserting  the  T-shaped 
current  charger  into  the  opening  marked  primary.  Its  strength  is 
regulated  by  the  sliding  coil.  Drawing  it  outAvards  increases,  and 
pushing  it  inwards  decreases  the  intensity. 

The  secondary  current  (strong)  is  obtained  by  moving  the  current 
charger  into  the  orifice  marked  secondary.  The  sliding  coil  should 
be  fully  drawn  out  to  the  right  hefore  this  change  is  made.  Pushing 
it  iuAvards  increases,  and  drawing  it  outwards  diminishes  the  inten- 
sity of  the  current. 

In  addition  the  power  of  either  current  can  be  increased  or  dimin- 
ished by  lowering  the  rod  more  or  less  down  into  the  battery  cell, 
being  greatest  when  entirely  down.  It  can  be  aflfised  in  any  posi- 
tion by  the  stay  screw. 

Even  when  in  daily  use  the  machine  will  continue  in  working 
order,  without  any  additional  charge,  for  a  considerable  period, 
depending  on  the  frequency  of  its  use.  Subsequently  when  the 
battery  fluid  becomes  weakened,  undo  the  screws  on  battery  and 
hydrostat,  empty  the  cell  and  refill  and  replace  all  as  before.  When 
the  zinc  plate  is  worn  out,  a  new  one  must  be  substituted. 

N.  B. — Do  not  forget  to  draiu  the  rod  up  and  rui  it  dry,  and  lay 
it  over  horizontally  immediately  after  use. 


PORTABLE  GALVANIC  BATTERIES. 

To  obtain  all  the  results  electricity  is  capable  of  producing,  it  is 
requisite  to  be  provided  Avith  both  an  electro-magnetic  machine  and 
a  galvanic  battery.  The  effects  derived  from  an  interrujjted  and 
a  continuous  curreni  being  in  many  respects  different.  The  electro- 
magnetic machine  is  the  instrument  most  fi'equently  required  for 
general  practice,  Avhile  the  galvanic  current  is  especially  used  in 
•certain  classes  of  nervous  disorders,  and  is  alone  applicable  for 
electrolysis  or  the  resolution  of  tumors.  This  is  owing  to  its  pos- 
isessing  chemical  powers,  of  which  the  faradic  or  induced  current 
is  almost  devoid. 

These  batteries,  an  improvement  on  Stohrer's,  are  also  exceedingly 
simple  and  very  easily  managed.  They  are  powerful,  reliable,  effi- 
cacious, continuous,  always  ready  for  immediate  use.  There  are 
three  sizes : 


158 


Orthop^bia. 


jSTo,  1.  Eight  cells,  suitable  for  eye  and  ear  cases,  and  where  a 
strong  current  is  not  requisite. 

No.  2.  Sixteen  cells,  for  general  use. 

No.  3.  Thirty-two  cells,  double  strength,  where  increased  power 
is  necessary,  and  for   electrolysis. 


GALVANIC    BATTERY. 
Fiy.  6i. 


These  instruments  can  be  had  with  or  without  either  the  hydro- 
stat  or  commutator. 

Directions  for  using  the  Portcible  Galvanic  Battery —  To  prepare 
the  hattery  fluid:  To  5  pints  of  cold  water  add  eight  ounces  of 
bichromate  of  potassa.  and  immediately  afterward  7  ounces  of 
sulphnric  acid  ;  mix  and  dissolve.     Cliarge  each  cell  1, 1, 1,  with  the 


Electricity  as  a  TUebapeutic  Agent.  159 

liquid  as  follows :  Lift  the  inside  box  B,  by  means  of  the  keys  2,  2, 
and  retain  it  in  position  by  turning  the  keys  half  round.  Remove 
the  slats  d  cl.  Place  a  glass  funnel  successively  into  each  cell,  and 
pour  in  the  fluid.  If  the  battery  is  provided  v^ith  a  hydrostat,  the 
cells  may  be  charged  two-thirds  full,  otherwise  only  two  ounces  to 
each.  Turn  the  keys,  lower  the  inner  box.  Insert  the  electrode 
pole  cords  into  the  binding  posts  P  and  N,  on  the  slide  or  com- 
mutator, which  is  movable  along  the  central  beam  C.  Replace  the 
slats.     It  is  then  ready  to  be  brought  into  action. 

When  required  for  use,  elevate  the  inner  box  as  before  and  secure 
it  in  position.  The  elements  are  thus  immersed  in  the  exciting 
fluid  and  the  battery  put  in  working  order.  When  the  slide  or 
commutator  is  brought  opposite  Fig.  2  on  the  front  slat,  the  current 
from  tw^o  cells  is  obtained ;  when  opposite  Fig.  4,  that  from  four 
cells,  and  so  on  to  Fig.  32.  By  thus  moving  the  slide,  to  the  left  or 
right,  the  intensity  of  the  current  is  increased  or  diminished.  It 
can  be  further  modified  by  raising  the  keys  to  the  fullest  extent  or 
only  partially,  and  turning  them  at  the  desired  elevation. 

The  improved  commutator  or  polarity  charger  for  the  galvanic 
battery  is  used  with  the  utmost  facility.  When  the  plate  marked  N, 
rests  over  the  letter  Z,  no  current  passes.  Wherever  the  plate  N, 
be  turned,  whether  to  the  right  or  left,  that  side  becomes  the  nega- 
tive, and  of  course  the  oi\\QV  2)ositive. 

N.  B.  — Always  lower  the  cells  immediately  after  use. 

When  tlie  battery  fluid  becomes  weakened  renew  it  as  before.  The 
exhausted  liquid  can  be  withdrawn  by  an  India-rubber  tube,  using 
it  as  a  syplion,  by  a  battery  syringe,  or  by  carefully  lifting  the  beam 
with  its  carbon  and  zinc  plates  attached,  raising  the  inner  box, 
emptying  and  replacing  one  cell  after  another,  filling  as  before,  and 
refixing  beam  and  plates. 

Sponges  should  be  fastened  to  the  extreme  points  of  the  handles 
of  the  electrodes  and  thoroughly  moistened  in  warm  water  previous 
to  each  application. 


160 


Orteop^dia. 


CABINET   EEGIILATOE   AND    BATTERIES. 
Fig.  65. 


The  above  engraving  represents  the  cabinet  galvanic  regulator;- 
with  drawers  for  the  batteries.  This  apparatus  is  complete,  witn 
current  selectors,  commutator  No.  1,  rheotome,  galvauoscope,  rheo- 
stat (water),  and  faradaic  coil.  The  galvanic  cells  (Siemen's  and 
Halske)  are  placed  in  the  drawers  of  cabinet,  and  are  connected 
with  the  regulator. 

To  the  physician  of  large  office  practice,  it  presents  an  instru- 
ment possessing  the  valuable  accessories  of  those  costly  apparatuses 
which  have  been  imported,  and  for  convenient  hospital  and  dispen- 
sary use,  it  is  almost  indispensable,  as  it  can  be  carried  from  ward 
to  ward,  and,  being  on  castors,  it  can  be  easily  moved  to  the  bed- 
sides of  patients. 

The  cabinet  is  of  black  walnut,  thirty-eight  inches  high,  seven- 
teen  inches  wide,  thirteen  inches  long. 


Electricity  as  a  Therapeutic  Agent. 


161 


baetlett's  kegulatok. 

Fig.  66. 


K,.e- 


The  above  engraving  represents  Bartlett's  Eegulator.  The  cur- 
rent selectors  A  1,  A  3,  enable  the  operator  to  unite  for  effect  any 
desired  number  of  elements,  from  two  to  sixty.  To  obtain  the  cur- 
rent from  28  cells,  turn  the  winch  A  2  to  20,  A  1  to  8.  While  if  we 
desire  only  4  cells,  the  winch  A  2  is  moved  to  the  letter  0,  the 
winch  A  1  to  4,     When  both  winches  are  at  0,  no  current  passes. 

The  rheotrope  or  commutator  C  changes  the  polarity  of  the  cur- 
rent, so  that  it  can  be  instantly  broken  or  reversed.  When  it  points 
vertically  the  current  ceases  to  pass.  When  the  winch  of  the  rheo- 
trope is  resting  on  N,  the  positive  current  passes  through  the  bind- 
ing post  c,  and  the  negative  through  the  binding  post  z.  If  the 
winch  rests  on  E,  the  positive  passes  through  z,  and  the  negative 
through  c.  When  the  battery  is  not  required  for  action,  let  the 
rheotrope  stand  vertically,  and  both  the  current  selectors  rest  on 
0,  and  by  this  means  the  elements  will  be  preserved  and  maintained. 

TJie  rheoto7ne,  or  cio'rent  interrupter  J,  causes  and  controls  fluc- 
tuations of  the  current.  When  the  knob  /,  rests  on  the  right  stop, 
no  break  is  experienced.  If  it  be  turned  gradually  to  thcj  left,  slow 
intermissions   are  felt;    so  that   the  greatest   rapidity    is   reached 


162  OrthoPuEdia. 

when  it  is  fully  turned  to  the  left.  Thus  we  have  the  means  of  in- 
creasing or  diminishing  the  interval  between  each  interruption  — 
an  object  of  the  greatest  therapeutical  importance." 

T7ie  current  modifiers  V  V,  weaken  or  intensify  the  strength  of 
the  currents.  The  glass  tubes  contain  water,  through  which  the 
rod  or  piston  passes  to  the  bottom  of  the  tube,,  and  there  remains 
in  contact  with  a  metal  conductor.  If  the  rod  be  elevated  from  this 
contact,  the  water  intervenes,  and  being  a  much  poorer  conductor, 
the  current  is  proportionally  weakened.  The  rod  should  be  raised 
by  a  kind  of  rotary  motion,  at  the  same  time  bearing  down  with 
the  other  hand  on  top  of  the  tube. 

The  galvanoscope  G.  If  the  winch  S,  stands  perpendicularly,  no 
current  passes  through  the  galvanoscope.  If']t  be  turned  toward 
either  side  the  needle  will  be  accordingly  deflected  ;  the  strength  of 
the  current  will  be  denoted  by  the  extent  of  the  deviations  of  the 
needle  from  the  point  0.  One  quarter  of  the  circle  is  the  full  extent 
to  which  it  can  be  deflected.  Having  obtained  the  desired  informa- 
tion, the  winch  S,  should  immediately  be  replaced,  as  otherwise  the 
sensibility  of  the  magnet  would  be  impaired.  If  the  circuit  be  open 
and  the  needle  deviates  on  either  side  from  the  point  0,  it  can  be 
replaced  by  turning  the  knob  J/,  to  the  right  or  left. 


Electricity  AS  A  Therapeutic  Agent.  163 


THE    GALVAXO-CAUSTIC    BATTERY. 


The  following  engraving  represents  a  full-sized  transportable 
galvano-caustic  battery,  an  improved  modification  of  Stohrer's 
and  Grennet's.  There  are  four  capacious  glass  cells,  each  contain- 
ing four  large  zinc  and  three  carbon  plates. 


Fig.  67. 


TO  PREPAKE  THE  BATTERY  FLUID. 

Pour  eight  fluid  ounces  of  sulphuric  acid  into  one  quart  of  Avater. 
After  this  has  cooled,  add  to  it  three  ounces  of  bichromate  of  pot- 
assa  roughly  powdered,  or  more  if  required  to  form  a  saturated 
solution.  If  after  stirring  and  dissolving,  a  few  crystals  remain  un- 
dissolved, it  will  be  advantageous,  as  they  will  be,  subsequently, 
utilized.  Ten  quarts  of  this  fluid  are  required  to  charge  the  four 
cells  of  the  galvano-caustic  battery.  The  front  of  the  tray  bears 
our  name-plate.  Cell  No.  1  is  on  the  left;  jSTo.  2,  back;  No.  3, 
right;  No.  4,  front. 

TO    ARRANGE   THE    BATTERY   AXD   EACH    PART   Ilf   POSITIOlsr. 

Place  the  glass  on  the  tray  on  each  side  of  the  lifting  partition ; 
insert  the  arm  marked  No.  1,  which  supports  the  elements  (zinc  and 
carbon)  into  the  opening  on  the  left  end  of  the  lifting  partition, 
marked  No.  1,  which  secures  it  in  position.  Then  place  arms  marked 


164 


Orthop^dia. 


2,  d,  4,  in  tlieir  position,  seeing  that  the  numbers  on  arms  correspond 
with  numbers  on  partition.  The  small,  crooked  brass  rods  are  for 
the  purpose  of  connecting  the  cells  together,  and  all  but  one  are 
notched  on  each  end  to  correspond  with  the  numbers  on  elements. 

The  blank  one  is  inserted  through  the  holes  in  these  protruding 
connections  on  first  cell,  which  connect  with  zincs,  and  connected 
to  the  small  permanent  binding  post  on  the  lifting  partition.  Eod 
notched  I  and  II,  is  connected  from  the  zinc  connectors  on  second 
cell,  and  through  the  hole  in  arm  of  cell  'No.  I.  Kod  notched  II 
and  III,  in  a  corresponding  way  with  Nos.  II  and  III.  Rod  notched 
III  and  IV,  from  III  to  IV  cell. 

See  that  all  the  hinding  screivs  are  screwed  firmly  doiun.  Elevate 
the  elements  by  means  of  the  central  lifting  screw  to  within  one 
inch  of  the  top  of  cells.  Fill  each  cell  about  three-quarters  full  of 
battery  fluid.  Attach  one  pole  cord  to  the  nipple  on  permanent 
binding  post  on  lifting  partition.  The  other  to  the  nipple  on  the 
arm  of  the  fourth  cell.  Thus  bringing  the  whole  number  of  ele- 
ments into  action.  When  only  three  cells  are  needed  for  use,  dis- 
connect the  rod  from  the  fourth  cell  and  attach  cord  to  second  cell. 
Same  with  one  cell.  When  the  zincs  or  carbons  become  crystallized, 
place  them  in  boiling  hot  water  and  allow  them  to  remain  until  the 
water  cools.     Then  dry  them  thoroughly. 

Fig.  68. 


rarri.^jv.  r. 


The  above  is  a  representation  of   a  case  containing  all  the  gal- 
vano-caustic    electrodes  in  situ. 
1.  Handle  for    looped   electrodes. 


Electricity  as  a  Therapeutic  Agent.  165 

2.  Stem  for  loops. —  Prepare  this  for  action  by  passing  the  wire 
through  its  dome ;  tubes  at  each  side  of  stem ;  holes  at  extremity 
of  handle  No.  I,  and  those  in  revolving  barrels ;  to  which  secure 
the  ends  of  the  wire.  The  flat  extremity  of  the  ivory  stem  and 
tubes  should  then  be  simultaneously  pressed  into  their  respective 
openings  at  the  end  of  the  handle,  and  securely  fastened  by  the  small 
binding  screws ;  place  the  ratchet  in  position ;  when  the  circuit  is 
closed  turn  the  barrel  gradually  by  its  handle  so  as  to  draw  tight 
the  loop  and  constrict  the  tumor. 

3.  Long  tubes  for  laryngeal  application,  nasal  polypi,  etc. 

4.  Short  tubes  for  loop.  The  wires  should  be  arranged  in  3  and 
4,  as  in  No.  2. 

5.  Universal  handle. —  The  upper  end  of  each  of  the  other  cau- 
teries can  be  inserted  in  the  socket  of  this  handle.  Be  particular 
that  the  brass  pieces  of  the  electrode,  to  be  used,  are  so  placed  in 
the  handle  that  they  rest  on  the  brass  sides  of  same,  in  order  that 
the  opening  in  the  handle,  and  the  ivory  in  centre  of  electrode 
should  be  on  a  line;  the  insulated  ring  should  then  be  forced  down 
to  firmly  fix  them  in  position. 

6.  Platina  point  cauterizer  for  concentrated  cauterization,  counter 
irritation,  etc. 

7-8-9.  Dome  cauteries  for  cauterization  of  sinuses,  bleeding  sur- 
faces, bases  of  ulcers,  places  where  cicatrical  contraction  is  desired 
for  the  destruction  of  small  growths,  etc. 

10.  Long  curved  stem  cauterizer  for  cavities,  tracks,  etc. 

11.  Straight  stem  cauterizer, 

12.  Galvanic  knife  cautery.  To  be  used  where  it  is  desired  to  slice 
off,  or  remove. 

13.  Right  angle  loop.     May  be  used  as  a  knife. 

14.  Galvanic  curette.  For  removal  of  small  fungoid  masses  or 
small  tumors. 

15.  Beak  cautery  for  counter-irritation.  To  be  used  with  low 
heat. 

16.  Short  curved  stem  for  cavities,  tracks,  etc. 

17.  Pocket  for  platina  wire  and  porcelain  domes. 

On  the  handles  1  and  5  are  slides  for  making  or  breaking  the 
connection. 


166  Orthop^bia. 

GAL  VANO- CAUTERY. 

Extracts  from  an  Article  by  Drs.  Allan  Hamilton  and  Ciias.  A. 
Warner,  New  York : 

"  The  advancement  of  surgical  science,  particularly  in  the  direc- 
tion of  Electro-therapeutics,  has  placed  a  most  yaluable  remedial 
agent  in  the  hands  of  the  profession. 

"  There  has  long  been  need  of  an  instrument  that  would  have  the 
advantage  of  being  used  in  inaccessible  parts  of  the  body,  where  the 
use  of  the  knife  is  attended  by  inconvenience,  or  forbidden  alto- 
gether. This  surgical  force  is  evidently  so  valuable,  so  efficient,  so 
universal  in  its  applicability,  that  it  will  eventually  to  a  great  degree 
take  the  place  of  the  knife  and  the  actual  cautery.        *         *  * 

"  It  is  found  that  if  a  poor  conductor  of  the  galvanic  current  is 
placed  between  two  exceedingly  good  ones,  it  will  undergo  a  marked 
elevation  in  temperature. 

"  From  a  knowledge  of  this  fact  we  find  that  if  such  a  substance 
as  platinum  is  made  the  terminal  arch  of  a  powerful  circuit,  where 
there  is  quantity  with  intensity,  it  will  be  instantly  raised  to  red 
heat,  and  if  the  current  is  sufficiently  strong,  it  will  become  incan- 
descent. This  power  has  therefore  been  recognized  and  the  galvano 
cautery  devised.  ****** 

"  These  instruments  have  been  modified,  and  we  now  have  a  num- 
ber of  varieties  of  form,  adapted  to  the  several  operations  we  wish 
to  perform.  The  most  important  variety  is  the  galvano-cautery 
loop  or  ecraseur,  which  may  be  used  for  the  removal  of  pediculated 
tumors,  such  as  polypi,  excrescences,  folds  of  tissue,  and  bands  of 
adhesions.  It  may  be  used  for  the  removal  of  polypi  of  the  larynx, 
uterus,  or  rectum ;  internal  hemorrhoids,  cauliflower  excrescences, 
or  for  amputation  of  the  cervix  uteri.  In  fact,  whenever  we  can  use 
the  ecraseur  for  the  removal  of  the  soft  parts,  we  can  employ  the 
Galvano-cautery  loop. 

"  The  second  variety  }ncludes  the  galvanic  moxa,  or  cone  of  porce- 
lain, which  is  heated  to  incandescence,  by  a  coil  of  platinum  wire, 
wound  about  it.  This  form  of  apparatus  is  used  when  the  desire  is 
to  produce  cicatrical  closure,  or  contraction,  as  in  the  vaginal  wall, 
where  prolapse  occurs,  the  basis  of  old  ulcers,  the  removal  of  small 
growths,  the  cauterization  of  bleeding  surfaces,  for  counter-irrita- 
tion^ and  for  bites  of  rabid  animals  or  reptiles. 

*•  The  third  form  is  the  galvanic  hnife  ;  this  is  employed  where 
the  desire  is  to  slice,  or  remove  masses  of  tissue,  degenerated  or 


Electricity  as  a  Therapeutic  Agent.  167 

indurated,  or  for  the  extirpation  of  growths  where  the  loop  is  con- 
tra indicated. 

"  There  are  several  modifications  of  this  form,  one  of  which  is  the 
galvanic  curette  ;  this  may  be  used  with  good  effect  when  the  aim 
of  the  operator  is  '  to  hoe,'  agriculturally  speaking.        *         *         * 

"In  the  performance  of  all  the  operations,  the  following  steps  are 
to  be  observed: 

"  1.  To  connect  the  Electrodes  with  the  battery. 

*'  2.  To  observe  that  the  connections  are  all  clean. 
■  "  3.  To  immerse  the  battery  plates  in  the  exciting  fluid  to  the  depth 
desired.  This  must  be  determined  by  the  color  of  the  heated  wire, 
or  platinum  extremity.  A  dull  red  heat  is  to  be  exceeded,  as  the 
cautery  is  very  apt  to  drag  or  tear  oflF  portions  of  tissue  and  cause 
hemorrhage.  A  white  heat  accompanied  by  scintillations  is  to  be 
avoided,  as  the  wire  is  very  apt  to  break  or  melt,  and  the  marginal 
inflammation  and  consequent  sloughing  will  be  serious. 

"'  4.  The  wire  should  always  be  tested  upon  a  piece  of  raw  meat, 
and  the  degree  of  "  severance  power "  gauged. 

"5.  The  patient  should  be  angesthetised  if  the  operation  is  of  con- 
siderable magnitude. 

"  6,  If  the  loop  be  used,  it  should  be  passed  about  the  part  to  be 
removed  cold,  and  when  m  situ  the  connection  made.  Then 
gentle  traction  should  be  exercised  by  the  rachet  wheel  in  the 
handle. 

"  7.  After  the  operation,  the  parts  should  be  treated  with  simple 
cold  water  dressing,  or  if  hemorrhage  follows,  it  may  be  stopped  by 
the  per-sulphate  of  iron.  *  *  * 

"  The  advantages  of  galvano  cautery  are :  that  there  is  seldom 
any  hemorrhage  ;  that  there  is  never  any  shock ;  that  the  cicatrix 
is  always  smooth ;  that  the  operation  is  easily  performed,  and  the 
separative  process  is  quick  ;  that  the  convalescence  is  short ;  and, 
finally,  that  the  procedure  is  simple,  and  almost  always  successful." 

In  relation  to  the  several  electrical  apparatus  now  in  use,  it 
would  be  unjust  were  we  not  to  mention  specially  those  of  Dr. 
Jerome  Kidder,  which  have  deservedly  gained  the  Prize  Medals  at 
the  annual  fairs  of  the  American  Institute,  and  at  the  Vienna 
Exposition,  and  are  continually  receiving  the  highest  encomiums  for 
excellence,  eflficiency  and  simplicity  of  construction  from  the  medi- 
cal fraternity  in  this  country,  as  well  as  in  Europe.  His  instru- 
ments commend  themselves  to  all  who  use  them,  and  mark  a  new 
era  in  Electrology. 


CHAPTER  VI. 

CONTRACTION  OF  THE  HANDS,  FINGERS  AND  TOES. 

Treatment  of  this  class  of  affections  liitlierto  most  unsatisfactory.  —  Section 
of  tendons  a  signal  failure. —  Ordinary  causes  of  contraction.  —  Muscular  par- 
alysis alone  accessible  to  influence  of  electricity  and  tenotomy.  —  Froriep,  of 
Berlin,  tlie  first  thorough  demonstrator  of  the  affection  in  all  its  details. — 
Baron  Dupuytren's  lectures  on  the  subject.  —  Method  pursued  in  dividing  the 
prolongations  of  the  palmar  fascia.  —  Contortion  and  ulceration  of  the  toes. — 
Bunyons.  —  Remedial  apparatus.  —  Contortion  of  the  toe-nails.  — Ulceration  of 
the  foot.  —  M.  Brachet's  practice.  —  M.  Somme's  treatment  of  morbid  growths. 
—  Sir  Astley  Cooper's  method  of  procedure.  —  Our  own  treatment.  — Onychia 
maligna.  —  Spastic  contortions.  —  Treatment. 


The  treatment  of  this  class  of  ailments  has  been  the  least  satis- 
factory of  all  the  ordinary  aberrations  from  normal  form.  Fixed, 
or  elastic  extension  has  afforded  little  or  no  relief  to  the  contracted 
wrist  or  hand.  The  toes  and  metatarsal  joints  have  been  much 
more  readily  relieved  by  appliances. 

The  section  of  tendons  in  the  hand  has  signally  failed  us  to  pro- 
duce good  results.  The  indications  for  the  operation  are  obscure, 
indefinable ;  and,  when  attempted,  have,  in  many  instances,  only 
impaired  what  little  remaining  usefuleness  there  was  in  the  fingers. 

The  most  common  causes  are  rheumatic  diathesis,  bruises,  injury 
to  the  bones,  fractures,  wounds,  abscesses,  cutaneous  eruptions  and 
paralysis  of  antagonizing  muscles.  The  latter  variety,  alone,  pre- 
sent a  favorable  condition  to  be  relieved  by  electricity  and  tenot- 
omy. The  tendons  are  resisting  and  prominent  beneath  the  skin, 
and,  with  a  knowledge  of  the  anatomy  of  the  part,  may  be  severed 
without  risk  of  injury  to  the  patient. 

The  impairment  is  rarely  limited  to  the  muscles,  and  commonly 
presents  a  combination  of  the  various  movements  of  the  hand  — 
flexion  being  accompanied  with  extension  of  the  fingers,  or  lateral 
inclination.  The  muscles  of  the  fore-arm  frequently  participate  in 
the  aflection,  and  are  more  or  less  flexed  or  pronated.  The  palmar- 
aponeurosis,  when  restricted,  may  aid  in  the  flexion  of  the  phalanges 
by  means  of    fibres  which  it  supplies  to  each  side  of  the  fingers. 


Contraction  of  the  Hands,  Fingers  and  Toes.     169 

Attention  was  first  attracted  to  this  fact  by  Froriep  of  Berlin. 
This  may  be  relieved  by  severing  the  tense  bands  of  fascia,  and  in 
some  cases,  the  partially  anchylosed  joints  may  be  relieved  by  forci- 
ble extension.  We  have  practised  both  with  snccess ;  bnt  in  the 
latter,  have  encountered  most  serious  results,  and  consequently, 
have  in  a  measure  abandoned  the  practice. 

When  the  ailment  is  confined  to  the  lateral  deviation  of  the  hand, 
the  severing  of  the  palmaris  longus  and  brevis,  and,  in  some  cases, 
the  flexor  carpi  ulnaris  is  necessary.  This  affords  almost  immediate 
relief,  if  it  is  not  due  to  paralysis  of  antagonizing  muscles,  when 
a  greater  duration  of  time  will  ensue  before  a  curs  is  obtained.  The 
subsequent  treatment  consists  in  making  an  effort  to  extend  the 
hand  by  means  of  suitably  contrived  elastic  extension. 

Experience  has  deterred  Orthopaedists  from  severing  tendons  at 
the  base  of  the  first  phalanx,  and  limited  the  practice  to  the  fore- 
arm for  the  relief  of  contracted  fingers.  Mr.  Franklin,  who  has 
had  the  most  extensive  practice  in  these  ailments,  says:  "Li  cases 
that  arise  from  injuries  to  the  fascia  itself,  and  in  which  the  tendon 
becomes  imbedded  in  the  cicatrix,  the  division  must  be  effected  at 
that  point.  You  cannot,  however,  in  this  instance  do  more  than 
straighten  the  fingers,  as  in  every  case  that  I  have  operated  upon, 
which  has  arisen  from  this  cause,  the  power  of  flexing  the  finger 
has  been  altogether  lost,  and  in  some  cases,  when  the  division  has 
been  performed  in  the  finger  itself,  in  which  the  integrity  of  the 
sheath  has  not  been  lost,  a  loss  of  power  has  been  the  consequence." 
This  accords  with  our  own  experience  in  dividing  tendons  at  the 
articulations  of  the  phalanges. 

For  the  most  practical  information  ever  given  on  this  subject 
we  are  indebted  to  Baron  Dupuytren  in  his  lectures  published 
by  the  Sydenham  Society  in  1854.  He  says,  "Most  of  those 
who  are  thus  affected  have  been  in  the  habit  of  using  force  with 
the  palm  of  the  hand,  and  of  handling  hard  bodies,  such  as  a  ham- 
mer, anchor  or  plough.  The  affection  usually  commences  in  the 
ring  finger,  when  it  extends  to  the  others,  especially  to  the  little 
finger,  and  increases  by  almost  insensible  degrees.  The  patient,  at 
first,  feels  a  little  stiffness  in  the  palm  of  the  hand  and  a  diflBculty 
in  extending  the  fingers  wnich  soon  become  a  quarter,  a  third,  or  a 
half  bent.  The  flexure  is  sometimes  carried  much  farther,  and  the 
extremities  of  the  fingers  are  bent  into  the  palm  of  the  hand. 
From  the  very  beginning,  a  cord  is  felt  on  tlie  palmar  surface  of 
the  fingers  and  hand,  which  is  drawn  tighter  when  an  effort  is 


170  Oethof^dia. 

'  made  to  straighten  the  fingers,  and  disapjoears  entirely  when  they 
are  quite  bent.  It  is  of  a  roundish  form,  and  its  most  salient  part 
is  at  the  articulation  of  the  finger  with  the  corresponding  metacar- 
pal bone,  where  it  forms  a  sort  of  bridge.  Its  extremities  are  lost, 
insensibly,  at  the  second  phalanx  of  the  finger  and  about  the  middle 
of  the  palm  of  the  hand ;  or,  perhaps,  short  of  this  point. 

"  The  skin  covering  the  finger  is  thrown  into  arched  folds,  the 
concavity  of  which  is  below,  and  the  convexity  above.  This  condi- 
tion is  for  a  time  limited  to  the  finger  primarily  affected,  but  at  a 
later  period,  the  other  fingers  are,  though  m  a  less  degree,  involved 
in  the  deformity. 

"  !N"otwithstanding  all  these  appearances  of  deep-seated  mischief, 
the  joints  of  the  affected  finger  show  no  trace  of  anchylosis,  and, 
without  excepting  even  the  first  phalanx,  they  cannot  be  straight- 
ened with  any  amount  of  effort,  and  I  have  seen  from  one  hundred 
to  one  hundred  and  fifty  pounds  weight  suspended  by  the  hook, 
which  the  finger  forms,  without  changing  its  position  a  line. 

"  The  ring-finger  is  incapable  of  extension,  and  the  others  will 
not  admit  of  it  completely ;  the  patient,  consequently,  cannot  lay 
hold  of  large  objects  ;  if  he  presses  anything  tightly,  he  experiences 
a  sharp  pain;  the  act  of  gripping  is  obstructed  and  causes  a  painful 
sensation.  When  at  rest,  there  is  no  pain  ;  and  none  is  felt  till  he 
endeavors  to  straighten  his  fingers  too  suddenly. 

"  The  following  short  description  of  the  palmar  fascia  will  show 
how  it  acts  in  producing  these  effects :  The  superficial  portion  of  the 
fascia  is  derived  partly  from  the  insertion  of  the  palmaris  longus 
tendon,  and  is  partly  a  prolongation  of  the  anterior  annular  liga- 
ment of  the  parpus.  At  its  commencement  it  is  very  strong,  and 
then  thins  off  gradually  toward  its  lower  edge,  dividing  iuto  four 
parts,  which  are  severally  directed  toward  the  heads  of  the  last  four 
metacarpal  bones.  Here,  each  of  these  processes  bifurcates  to  admit 
of  the  passage  of  the  flexor  tendons,  and  either  subdivision  keeps 
along  the  sides  of  the  phalanges  and  not  in  front,  as  many  anato- 
mists have  described.  It  is  these  prolongations  which  are  more 
stretched  than  the  fascia,  and  Avhich  require  to  be  divided.  When 
the  skin  and  the  fascia  are  dissected,  there  is  some  difficulty  in  sep- 
arating them,  owing  to  the  cellular  tissue  and  some  fibrous  prolonga- 
tions which  arise  from  the  fascia.  These  adhesions  account  for  the 
puckering  and  movement  of  the  skin.  In  cutting  through  these 
fibrous  prolongations  it  might  be  apprehended  that  the  nerves  and 


Contraction  of  the  Hands,  Fingers  and  Toes.     171 

vessels  would  be  involved,  but,  when  the  fascia  is  in  a  state  of  ten- 
sion it  forms  a  sort  of  protecting  arch  across  them,  so  that  it  may 
be  cut  without  danger.  The  use  of  the  palmar  fascia  is  to  support 
the  tendons  of  the  flexor  muscles,  to  preserve  the  palmar  arch,  and 
generally  to  protect  the  rarious  parts  of  the  hands.  In  roosting 
birds  it  is  very  largely  developed,  and  is  remarkably  elastic.  Such 
are  the  functions  usually  attributed  to  the  palmar  fascia;  but  it 
has  others,  whereby  it  tends  to  keejD  the  fingers  semi-flexed,  which 
is  their  natural  position  in  a  state  of  repose  ;  and  tbis  function, 
when  exaggerated  by  disease,  produces  contraction  of  the  fingers." 
The  operation  of  dividing  these  prolongations  of  the  palmar  fascia 
consists  in  supinating  the  hand  and  extending  the  fingers  as  much 
as  possible.  A  transverse  incision  is  made  Avith  a  bistoury,  di\iding 
the  skin  opposite  the  metacarpo-phalaugeal  articulation  of  the  con- 
tracted finger  ;  then  the  tense  prolongations  of  the  palmar  fascia, 
which  will  respond  with  a  crackling  noise  and  the  straightening  of 
the  finger.  As  a  matter  of  precaution  against  wounding  the  nerves 
and  blood  vessels,  the  tense  fascia  should  be  divided  slowly,  and  its 
division  determined  by  the  yielding  of  the  restrained  finger  —  each 
finger  to  be  operated  on  separately.  Tense  bands  may  be  observed 
in  the  palm  of  the  hand,  in  which  case  they  should  be  divided  in  a 
similar  manner ;  as  the  thick  integument  covering  the  palm  of  the 
hand  is  more  or  less  implicated  in  the  abnormal  condition.  Means 
of  extension,  elastic  if  possible,  should  be  applied  to  the  back  of  the 
hand,  and  simple  water  dressings  to  the  palmar  surface.  The 
wounded  parts  heal  slowly,  and,  at  times,  with  considerable  pain 
and  swelling,  but  finally  without  any  very  serious  difficulty.  Flexion 
of  the  fingers  may  be  attempted  in  about  fifteen  days,  and  the  treat- 
ment completed  in  about  twenty  days. 

Mr.  William  Adams,  F.E.C.S.,  of  London,  Surgeon  to  the  Great 
Northern  Hospital,  Consulting  Surgeon  to  the  National  Orthopaedic 
Hospital,  etc. ,  read  before  the  Royal  Medical  and  Chirui'gical  Society, 
May  22d,  1877,  a  ^oaper  describing  the  various  procedures  by  emi- 
nent surgeons  tending  to  the  relief  and  cure  of  contracted  palmar 
fascia,  producing  deformity  of  the  fingers.  He  gave  special  promi- 
nence to  the  method  of  Baron  Dupuytren,  who  lectured  in  the 
Hotel  Dieu,  Paris,  in  the  Session  of  1831  and  1832,  with  critical 
remarks  upon  the  treatment  of  this  serious  impairment  of  the 
hand. 

Mr.  Adams,  in  his  paper,  describes  a   most  valuable    and  sue- 


172  OrthopuEdia. 

cessful  surgical  procedure  for  the  relief  of  this  distressing  ailment, 
in  the  following  address  : 

"T  commenced  the  practice  of  making  multiple  subcutaneous 
divisions  of  the  fascia,  introducing  the  smallest  tenotomy  knife — 
smaller  than  any  ordinarily  used,  passing  it  between  the  skin  and 
the  contracted  cord,  which  I  then  divided  by  cutting  downwards 
very  slowly  and  cautiously,  taking  care  not  to  dip  the  point  of  the 
knife,  nor  divide  any  structure  except  the  contracted  band  of  fascia. 
In  one  case,  where  three  fingers  were  contracted,  I  made  as  many 
as  nine  punctures  and  subcutaneous  divisions ;  but  where  so  much 
is  required  to  be  done,  I  think  it  generally  advisable  to  confine 
the  operation  to  one  or  two  fingers,  making  not  more  than  five  or 
six  punctures — in  many  cases  four  will  be  found  sufficient — and 
leave  the  other  finger  or  fingers  for  a  subsequent  operation. 

"As  a  rule,  I  make  ila.e  first  puncture  at  the  greatest  distance  from 
the  finger  in  the  palm  of  the  hand  towards  the  annular  ligament,  a 
little  removed  from  the  point  where  the  skin  is  adherent  to  the 
fascia,  and  where  the  skin  is  not  tightly  stretched  over  the  con- 
tracted cord,  so  that  the  tenotomy  knife  can  be  readily  introduced 
between  the  two.  The  second  puncture  should  divide  the  same  cord 
a%s  the  first,  but  as  near  to  the  finger  as  possible,  thus  leaving  the 
contracted  band  in  the  palm  of  the  hand,  when  adherent  to  the 
skin,  isolated  and  cut  off:  from  its  connections  at  its  upper  and  lower 
extremities. 

"The  third  and  fourth  punctures  divide  the  lateral  bands  or  digi- 
tal prolongations  of  the  palmar  fascia,  which  usually  pass  from  the 
central  cord  in  the  palm  to  the  adjacent  sides  of  the  fingers.  These 
must  be  divided  very  carefully  in  order  to  avoid  cutting  the  vessels 
and  nerves  along  the  sides  of  the  fingers.  The  punctures  should 
be  made  at  the  bifurcation  of  the  cutaneous  net  between  the  fingers, 
and  the  incision  directed  obliquely  upwards  and  outwards  toward 
the  palm  of  the  hand. 

"  These  incisions  will  divide  the  strongest  and  most  prominent 
bands  which  produce  the  flexion  of  the  first  phalanx  of  the  finger 
upon  the  hand,  and  if  care  be  taken  to  avoid  dipping  the  point 
of  the  knife,  there  will  be  no  fear  of  wounding  vessels  or  nerves. 
Sometimes  lateral  bands  of  contracted  fascia  require  to  be  divided 
opposite  the  centre  of  the  first  phalanx,  and  this  must  be  done  by 
puncture  at  the  edge  of  the  contracted  bands,  the  knife  being 
directed  transversely  toward  the  bone,  but  this  cut  must  be  made 
very  carefully  to  avoid  the  artery  and  nerve ;  the  surgeon  remem- 
bering that  the  band,  though  tough  and  strong,  is  at  the  same  time 


Contraction  of  the  Hands,  Fingers  and  Toes.    173 


Tery  thin.  These  bands  are  more  readily  cut  through  with  a  scis- 
sor-pointed  tenotome,  i.  e.,  with  the  point  at  the  extremity  of  the 
straight  cutting  edge.  The  central  pointed  tenotome  generally 
used  does  not  divide  the  fascial  bands  so  readily,  or  with  the  same 
precision.  Occasionally  a  lateral  band  may  have  to  be  divided 
between  the  first  and  second  phalanges,  at  a  point  corresponding 
to  the  articulation,  and  this  must  be  done  very  carefully  with  the 
precautions  just  described. 

"  I  always  avoid  making  any  central  incisions  in  front  of  either 
the  first  or  second  phalanx,  as  the  sheath  of  the  tendons,  or  the 
^*^-  ^^-  tendon  itself,    may   be   readily   di- 

vided by  such  incisions,  and  would 
lead  to  a  loss  of  power  of  flexing 
the  finger  after  the  operation. 

"  Subsequently,  I  also  adopted  an- 
other important  modification  in  the 
after  treatment  of  these  cases,  viz., 
the  plan  of  immediate  extension, 
bringing  the  finger  or  fingers  as 
nearly  as  possible  into  a  position 
of  complete  extension  at  the  time 
of  the  operation,  and  afterwards 
applying  as  a  retentive  apparatus  a 
well  padded  metal  splint,  bent  to 
the  shape  of  the  wrist,  hand  and 
fingers,  and  applied  along  the  palmar 
surface,  the  finger  or  fingers,  as 
well  as  the  hand  and  wrist,  being 
bandaged  to  the  si^lint,  as  shown  in 
the  annexed  engraving."  (Fig.  69.) 
It  was  my  jDleasure  to  be  invited 
by  Mr.  Adams  to  lunch  with  him  and  the  gentleman  upon  whom- 
Mr.  A.  performed  his  first  modified  ojDeration  upon  the  contracted 
palmar  fascia ;  the  result  of  this  adventure  being  a  most  perfect 
success,  the  gentleman's  hand  being  restored  to  normal  usefulness. 
A  most  enterpi'ising  young  surgeon,  Robert  Abbe,  M.D.,  Surgeon 
to  the  Out-door  Department  of  the  New  York  Hospital,  and  Con- 
sulting Surgeon  to  the  Hospital  for  the  Ruptured  and  Crippled, 
and  now  Surgeon  to  St.  Luke's  Hospital,  also  states  as  follows  : 

"The  case  I  am  about  to  relate  is  a  perfect  type  of  this  rare 
trouble,  and  presents  one  or  two  features  of  special  interest. 

"The  patient,  rather  a  large  man,  aged  forty-five  years,  came  to 


174 


Orthop^bia. 


me  June  9tli,  1881.  He  had  been  a  cloth-cutter  for  fifteen  years ;  had 
never  had  syphihs,  rheumatism  or  gout.  His  occupation  required 
the  use  of  large  scissors  in  his  right  hand,  but  nothing  in  his  left. 

"  Seven  years  ago  the  left  httle  finger  began  to  draw  down  toward 
the  palm  without  known  provocation,  and  had  grown  progressively 
worse  until  it  rested  flat  on  the  palm  of  the  hand,  though  it  could 
be  raised  by  a  little  force  to  the  extent  shown  in  figure  (see  Fig.  70). 

"One  year  ago  the  ring  finger  of  the  right  hand  began  to  con- 
tract in  the  same  fashion,  and  had  progressively  become  worse  until 
it  was  as  shown  in  figure  71." 

Dr.  Abbe  proceeded  to  operate  as  after  the  subcutaneous  pro- 
cedure of  Mr.  Adams,  to  the  most  successful  relief  of  this  man, 
and  upon  several  others  since,  being,  as  I  believe,  the  first  in  this 
country  to  perform  the  operation  upon  the  contracted  palmar  fascia 
as  performed  by  Mr.  Adams,  of  London. 

Fig.  70. 


Fig.  71. 


CONTORTION  AND  ULCERATION  OF  THE  TOES. 
Contortion  of  the  toes  may  arise  from  various  causes,  but  more 
especially  from  wearing  tight  shoes  or  boots.  A  most  painful  ail- 
ment arises  from  inflammation  of  the  joint  of  the  metatarsal  bone 
with  the  first  phalanx,  in  which  case  more  or  less  thickening  is 
found  in  the  joint,  and,  of  course,  impediment  in  walking.  The 
individual  under  such  circumstances  instinctively  retains  the  toe  in 


Contraction  op  the  Hands,  Fingers  and  Toes.    175 


the  flexed  position,  which  terminates  in  a  permanent  contortion  of 
the  toe  as  connected  with  the  foot.  Lateral  flexion  is  most  common, 
and  terminates  in  an  abnormal  development  of  the  metatarso — pha- 
langeal joint  of  the  great  toe,  which  becomes  exceedingly  sensitive, 
and  is  commonly  known  as  a  hunynn.  Upon  extending  the  toe, 
the  long  flexor  will  be  found  rigidly  tense,  and  may  be  severed  in 
the  sole  of  the  foot,  introducing  the  knife  outside  of  the  tendon, 
passing  it  beneath,  and  dividing  from  below  upwards;  in  this  way 
the  puncturing  of  the  internal  plantar  artery  can  be  avoided,  and 
then  an  apparatus  should  be  applied  as  seen. 

Fiu.  72.  This  consists  of  a  delicate   spring 

plate,  shaped  to  conform  to  the  parts 
to  which  it  is  to  be  applied,  and  a  point 
of  steel  extending  the  length  of  the 
toe,  to  which  is  attached  a  piece  of 
soft  leather  to  pass  around  the  con- 
torted toe  and  restore  it  by  the  lacing 
to  a  normal  condition.  This  apparatus 
will  cure  the  ailment  when  the  sever- 
ing of  the  tendon  is  not  so  directly 
indicated,  and  an  ordinary  shoe  can 
be  worn  over  it  without  cansing  much  of  an  unseemly  appearance. 

For  the  relief  of  the  other  toes,  when  contorted,  an  apparatus  is 
employed,  comprising : 

A  steel  plate  shaped  to  the  anterior 
portion  of  the  sole  of  the  foot,  having 
openings  or  slits  made  to  correspond 
to  the  projections  of  the  toes;  soft 
leather  slips,  four  inches  in  length, 
with  the  portion  to  cover  the  toe 
about  one  inch  in  .width,  tapering  off 
so  as  to  be  tied  on  the  under  side  of 
the  plate.  By  this  the  toes  can  be  brought  down  and  retained  in 
situ  without  pain  to  the  patient,  and  be  worn  with  the  shoe  or  boot. 
In  severe  cases  the  tense  tendons  should  be  severed  to  facilitate  the 
case;  as  no  injury  will  follow  the  operation  —  water  dressing  for  a 
vv^eek,  and  the  plate  then  applied  completes  the  cure. 

The  great  toe-nail  and  its  connection,  or  matrix,  is  subject  to 
disease  of  a  most  painful  character  and  of  frequent  occurrence. 
This  disease  is    never  found  in  the  hands,  and  is  usually  confined 


Fig.  73. 


176  ORTHOPjEDIA. 

to  the  great  toe.  Contortion  of  the  nail  inward,  the  result  of  the 
direction  of  pressure,  as  from  that  of  the  surrounding  shoe, 
may  be  considered  as  a  common  cause,  and  in  a  degree  equal  to  its 
close  approximation  and  cramping  of  the  toes.  This  pressure  forces 
the  angles  of  the  nail  into  the  fold  of  the  skin  on.  the  inner  side 
of  the  toe,  extending  laterally  by  growth,  and  from  irritation,  the 
fold  becomes  swollen  as  well  as  aggravated  by  the  adjoining  toe 
pressing  upward  and  over  the  nail.  This  irritation  is  increased  by 
walking,  and  a  very  painful  inflammation  ensues.  The  flesh  being 
injured,  a  sero-purulent  oozing  takes  place,  and,  from  walking,  the 
whole  foot  eventually  becomes  implicated,  while  the  oozing  becomes 
more  abundant  and  fetid,  as  it  mingles  with  the  perspiration  of  the 
foot.  If  not  relieved,  the  ulcerated  condition  degenerates,  under  an 
unfavorable  condition  of  health,  into  a  cancerous  sore,  or  fungoid 
excrescences;  and,  in  some  of  these  conditions,  the  inflammation 
extends  to  the  periosteum,  giving  rise  to  caries  or  necrosis  of  one 
or  more  of  the  phalanges. 

Various  modes  of  treatment  have  been  practised,  one  of  which  is, 
that  of  attempting  a  cure  by  elevating  the  nail,  pressing  lint  under 
the  edge,  applying  caustic  to  the  morbid  growth  and  cutting  the 
nail  frequently.  These  proceedings  must  be  considered  as  only  pal- 
liative rather  than  curative.  The  more  severe  means  has  been  ta 
cut  away  all  of  the  overgrown  flesh,  thus  permitting  the  nail  to 
extend  down  the  side  of  the  toe.  This  last  was  the  practice  of  M. 
Brachet.  M.  Somme,  a  surgeon  of  Antwerp,  cut  off  the  portion  of 
the  nail  growing  into  the  flesh  and  then  filled  the  cavity  with  pow- 
dered alum,  which  he  said  dried  up  the  ulcer  and  prevented  the 
growth  of  the  nail.  Sir  Astley  Cooper  recommended  the  thinning 
of  the  nail  with  a  bistoury,  and  the  introduction  of  a  small  roll  of 
lint  beneath  the  point  disengaged  from  the  flesh;  when  active  in- 
flammation, however,  prevented  the  introduction  of  the  lint,  he  tore 
off"  the  nail  with  forceps. 

Our  practice  has  been,  in  the  incipient  stage  of  the.  ailment,  to 
cut  the  free  or  distal  portion  of  the  nail  straight  across,  thus 
forming  two  free  angles,  under  which  lint,  to  a  considerable  amount, 
can  be  forced  without  inducing  much  pain.  The  nail,  being  thus  ele- 
vated, overlaps  the  flesh,  and,  if  carefully  persevered  in,  arrests  the 
tendency  to  this  painful  disease  of  the  great  toe.  This  practice  serves 
well  for  children,  whose  toes  should  be  frequently  examined,  and  if 
the  least  tendency  toward  impingement  of  the  nail  upon  the  flesh  of 


Contraction  of  the  Hands,  Fingers  and  Toes.    177 

fche  inner  side  of  the  great  toe  be  perceptible,  the  nail  should  be  pared 
as  described  above.  Children  of  five  or  six  years  of  age,  wearing- 
shoes,  are  very  liable  to  this  painful  condition  of  the  toe.  In  exag- 
gerated cases  of  considerable  duration,  and  attended  with  much 
swelling,  the  patient  is  placed  at  rest,  and  the  toe  poulticed  until  the 
pain  and  swelling  have  somewhat  subsided  ;  then,  with  a  pair  of  strong 
sharp-pointed  scissors,  divide  the  nail  by  pressing  one  of  the  points 
to  the  root  of  the  nail  and  about  a  line  from  the  overlapping  flesh. 
Then  seize  the  segment  that  is  penetrating  the  flesh  with  a  strong 
pair  of  forceps  and  tear  it  away  from  its  attachments.  Plain  water 
dressing  is  all  that  is  required  for  the  subsequent  treatment  in  ordi- 
nary cases,  and,  in  a  week  or  ten  days,  the  paitient  will  be  able  to 
wear  a  shoe  without  pain  —  nor  is  the  operation  so  painful  as  might 
be  imagined,  and  when  the  nail  is  removed  there  is  no  return  of 
the  disease  in  ordinary  cases,  if  treated  as  in  the  incipient  stage  of 
the  ailment. 


ONYCHIA  MALIGNA. 


In  1814,  Mr.  Wardrop  wrote  an  article  npon  the  treatment  of  this 
ailment,*  which  appears  to  be  an  ulceration  of  the  matrix  of  the 
great  toe-nail,  quite  different  from  in-growing  nail,  requiring  special 
treatment.  It  is  a  peculiar  morbid  condition  of  the  integument  at 
the  root  of  the  nail,  tending  to  the  alteration  of  the  structure  of 
the  nail  and  results  from  violence  done  the  toe  —  inflammation  fol- 
lowing sooner  or  later.  Baron  Dupuytren  writes  as  follows  upon 
this  disease : 

"These  cases  may  frequently  be  due  to  the  action  of  syphilitic 
virus,  and  occurring  at  the  matrix  of  the  nail,  they  have  been  named 
onglade. 

"1st.  It  affects  the  nails  of  the  feet  and  hands,  indiscriminately. 

"  2d.  It  attacks  several  at  once. 

"  3d.  It  shows  itself  in  small  ulcers  at  the  intervals  between  the 
fingers,  whence  it  spreads  to  the  circumference  of  the  nails. 

"'4th.  The  nail  is  detached  spontaneously  from  the  integument. 

"  5th.  It  resists  all  anti-syphilitic  remedies  ;  and,  setting  aside  all 
the  peculiarities  I  have  named,  the  most  experienced  surgeon  would 

*Med.  Cliir.  Trans.  Vol.  V,  page  129. 


178  Or  thopjEdia  . 

have  difficiTlty  in  clistiugnisliiug  it  from  common  inflammation   of 
the  matrix  of  tlie  nail."  * 

The  ailment  may  be  considered  as  an  indication  of  some  consti- 
tutional derangement,  curable  by  a  strict  regimen,  rather  than  medi- 
cine, as,  in  some  cases,  the  nail  being  cast  off,  the  cure  is.  effected, 
while  in  others  the  cure  is  only  accomplished  by  the  removal  of  the 
nail,  and  even  the  matrix  of  the  naiL  In  this  ailment  fungous 
growths  w411  be  found  at  the  base  of  the  nail,  and  not  at  the  side  as 
in  that  of  the  ingrowing  nail.  The  diseased  member  is  of  a  violet 
red  color  and  very  painful ;  the  nail  is  shortened  and  reduced  in 
breadth ;  sometimes,  indeed,  it  has  wholly  disappeared,  and,  instead 
of  a  nail,  there  are  only  some  traces  of  a  horny  substance  ;  the  nail, 
too.  is  frequently  concealed  beneath  the  fungous  flesh.  Its  color  is  gray 
or  black,  and,  in  some  cases,  it  is  not  adherent,  as  in  the  normal 
state,  and  the  morbid  growths  discharge  a  serous  pus  of  a  most  fetid 
odor,  bleeding  freely  Avhen  the  patient  attempts  to  walk.  When  in 
this  pitiable  condition,  which  medicine  will  not  relieve,  their  pres- 
ence cannot  be  endured  in  the  room  with  others,  because  of  the 
stench,  and  nothing  but  the  knife  and  a  generous  diet  will  afford 
relief.  The  matrix  of  the  nail  and  all  of  the  diseased  growths  must 
be  carefully  removed.  In  performing  the  operation  the  patient  re- 
clines on  a  bed  and  receives  an  anaesthetic,  as  the  pain  is  necessarily 
severe ;  the  foot  is  then  drawn  over  the  side  of  the  bed  and  is  held 
and  supported  on  the  knee  of  an  assistant.  A  deep  semi-circular 
incision  is  made  with  a  straight  bistoury,  about  three  lines  from, 
and  parallel  to,  the  elevated  fold  at  the  base  of  the  nail.  The  dis- 
eased parts  are  then  taken  hold  of  by  the  forceps,  and,  with  the  nail, 
are  all  carefully  dissected  out  so  as  to  remove  all  the  diseased  flesh 
in  that  region.  Simple  dressing  is  all  that  is  required  ;  the  surface 
of  the  denuded  parts  are  soon  covered  with  healthy  granulations 
which  must  be  controlled  with  nitrate  of  silver.  In  fifteen  or 
eighteen  days,  usually,  the  patient  can  wear  a  shoe,  and,  in  time,  a 
smooth  thick  skin  assumes  the  place  of  the  nail. 


SPASTIC     COXTORTIOXS    AXD    THEIR    TREATMENT. 

Children  laboring  under  contortion,  from  spastic  contraction  of 
muscles,  usually  attributed  to  convulsions  before  and  after  birth, 

*  Published  by  Sydenbam  Society,  1854,  page  254. 


Contraction  of  the  Hands,  Fingers  and  Toes.  1*79 

are  subjects  for  relief  in  many  instances.  It  is  not  safe,  however, 
(although  usually  not  so  considered)  to  give  a  favorable  prognosis 
in  these  cases,  as  some  patients  may  be  greatly  benefited  by  a  judi- 
cious perseverance  in  treatment,  while  others  fail  to  be  improved. 
The  spastic  influence  is  manifested  in  nearly  all  the  muscles  of  the 
body  and  limbs.  The  arms  are  folded  firmly  to  the  body,  and  the 
hands  flexed  in  a  pronated  position  which  they  are  inclined  to  con- 
stantly maintain.  The  contortions  of  the  muscles  of  the  face  give 
the  patient  an  idiotic  appearance,  though  the  mind  is  in  a  normal 
condition.  The  legs  are  partially  flexed  with  irregular  tension ;  the 
limbs  adducted,  and  the  heels  elevated;  presenting  a  seeming  case 
of  talipes  equinns,  which  greatly  inconveniences  the  patient  upon 
attempting  to  walk,  and,  in  some  cases,  subjecting  him,  after  arriv- 
ing at  the  age  of  eight  or  ten  years,  to  the  constant  use  of  crutches; 
while  in  extreme  cases,  to  the  dependent  condition  of  being  unable 
to  convey  food  to  the  mouth  or  to  move  about  in  any  other  way  than 
by  hitching  upon  the  floor. 

The  treatment  of  this  class  of  ailments  is  by  no  means  as  satis- 
factory as  that  we  have  been  treating  of.  In  this  we  have  contor- 
tions and  irregularities  of  naotion,  the  result  of  involuntary  and 
uncontrollable  movement  of  all  the  muscles ;  not  shortened  muscles, 
from  a  want  of  normal  antagonistic  force,  but  muscles  impaired  by 
the  loss  of  mental  control,  resulting  in  a  persistent  condition  of  the 
sound  muscles.  The  equilibrium  of  action  is  restored  in  some  cases, 
by  severing  the  tendons  of  the  shortened  muscle,  thus  permitting 
the  extended  muscle  to  contract  to  a  normal  condition,  such  ten- 
dency existing  in  the  extended  muscles.  The  division  of  tendons, 
however,  in  this  peculiar  condition  of  the  patient  often,  in  time, 
restores  to  them  the  control  of  their  feet.  From  this  result  it  would 
seem  rational  to  suppose  that  a  dynamic  influence  is  thereby  im- 
parted, tending  to  a  more  normal  condition  of  muscular  movement 
by  an  impression  made  upon  the  motor  nerves.  We  do  not  hesitate, 
in  this  ailment,  to  divide  the  tendons  that  appear  to  be  the  cause 
of  contortion  of  the  limbs,  and  in  some  cases  to  a  great  improve- 
ment of  the  patient's  previous  condition,  applying,  of  course,  sup- 
ports as  in  other  ailments  requiring  them.  This  treatment  applies 
mainly  to  the  relief  of  the  lower  extremities.  The  arms  and  hands 
are  much  improved  by  systematic  exercises;  always  limiting  the 
amount  to  the  accomplishment  of  one  feat  before  another  is  attemp- 
ted.    Patients  unable  to  feed  themselves  have  thus  been  enabled  to 


180  Or  thop^dia  . 

perform  for  themselves  more  of  tlieir  necessary  personal  requirements 
than  would  be  supposed  possible  for  them  to  do  in  their  decrepit 
condition,  and  the  result  obtained  will,  in  a  majority  of  instances, 
amply  repay  the  effort  of  teaching  them.  They  may,  also,  be  much 
improved  by  passive  exercise;  as  that  of  manipulating  the  tense 
muscles,  shampooing  and  inducing  them  to  perform  some  agreeable 
labor  that  will  require  a  control  of  the  muscles ;  when,  it  will  be 
observed  that  by  perseverance  and  time,  seeming  impossibilities  will 
be  overcome.  Many  whom  we  have  treated,  years  ago,  are  now  en- 
joying all  the  immunities  of  social  life  as  though  they  had  never 
been  so  afflicted ;  others  have  been  much  relieved  from  their  de- 
pendent condition,  and  only  a  very  limited  number  remained  that 
were  not  improved.  The  encouragement  we  have  had  from  great 
perseverance  in  treatment,  induces  us  to  advise  that,  in  all  cases 
where  the  mental  faculties  are  not  greatly  impaired,  this  afflicted 
class  should  be  afforded  the  benefit  of  a  decided  effort  for  their  re- 
lief; and  more  especially  as  their  mental  faculties  are  usually  in  a 
normal  condition.  The  impediment  of  speech  caused  by  the  spas- 
modic action  of  the  muscles  of  the  tongue,  and  interrupting  the 
correct  expression  of  thought,  tends  to  apparent  imbecility  of  the 
patient,  and  should,  of  course,  be  carefully  considered ;  and  bear  in 
mind  that  there  is  not  co-ordinate  action  of  mind  and  muscle  in 
this  abnormal  condition,  but  that  tuition  can  be  made  available  to 
much  improvement,  by  directing  the  patient  to  concentrate  an  effort 
of  the  will  upon  one  movement  of  one  limb  at  a  time ;  and  when  the 
movement  is  perfected,  another  may  be  commenced,  but  not  before, 
as  confusion  will  be  the  result,  tending  to  failure  in  the  treatment. 
There  is  no  other  ailment  that  we  have  to  treat,  susceptible  of  any 
degree  of  improvement,  that  requires  the  same  amount  of  perse- 
verance and  length  of  time  to  accomplish.  Five,  and  even  ten  years 
of  constant  effort  has,  in  some  cases,  enabled  helpless  individuals  to 
a  tolerable  condition  of  independence  and  self-assistance. 


CHAPTEE  VII. 

LATERAL    CURVATURE  OF  THE  SPINE  —  TORTICOLLIS. 

Congenital  lateral  curvature  of  tlie  spine.  —  Co-existenc  e  of  this  contortion 
in  foetal  monstrosities  ;  how  caused.  —  Symptoms  usually  observed.  —  Prog- 
nosis of  cure.  —  Non-congenital  curvature  of  the  spine. — Various  conditions 
of  aberration. —  Oblique  abdominal  muscles  largely  contribute  to  the  con- 
tortion.—  Direct  or  reflex  irritation,  under  certain  circumstances,  tends  to 
increase  curvature.  —  Pathological  condition  tending  to  lateral  curvature.  — 
Mr.  Barwell  on  internal  organic  lesions,  their  causes  and  treatment.  —  The 
female  more  subject  to  this  affection  than  the  male,  though  men,  vromen 
and  children  are  liable  to  it. — Pneumonia  and  pleurisy  as  predisposing 
causes.  —  Diagnosis  of  lateral  curvature  of  the  spine.  —  Two  cases  rarely  found 
alike  in  diagnosis  —  First  stage  of  curvature.  —  Second  stage.  —  Third  stage.  — 
Treatment  of  lateral  curvature  of  the  spine.  — The  general  opinion  that  curva- 
ture of  the  spine  is  less  amenable  to  treatment  than  other  contortions,  errone- 
ous. —  Accurate  diagnosis  of  abnormal  developments  and-  general  health  of 
patient  the  primary  requisite.  —  Parallel  bars,  their  utility.  —  The  supporting 
apparatus.  —  Description  of  extension  chair.  —  Barwell's  description  of  the  ad- 
vantage resulting  from  the  use  of  chair.  — The  patient's  health  a  primary  con- 
sideration. —  The  skilled  medical  practitioner  the  most  competent  to  give  pri- 
mary relief. —  Beneficial  effect  of  calisthenic  exercises.  —  The  use  of  electricity 
not  beneficial,  and  objectionable  as  a  therapeutic  agent  in  spinal  curvature.  — 
Tenotomy  as  a  means  of  cure.  —  Guerin,  of  Paris,  the  first  to  attempt  dorsal 
myotomy.  —  Want  of  perseverance  in  treatment  the  most  serious  difficulty. — 
Torticollis,  what  it  is,  and  how  it  should  be  treated.  —  Electricity  applica- 
ble. —  Division  of  the  Sterno-cleido-mastoideus  muscles  resorted  to  two 
centuries  since.  —  The  sub-cutaneous  method  now  generally  adopted.  — Bon- 
net's method  of  procedure. 


CONGElSriTAL   LATERAL   CURVATURE   OF   THE    SPINE. 

The  co-existence  of  this  contortion  in  fcetal  monstrosities  has 
tended  to  the  conclusion  that  the  muscular  contraction  resulting  in 
lateral  flexion  of  the  spine  of  the  foetus  is  caused  by  tonic  spasm  from 
lesion  in  the  nervous  centres,  and  not  malposition,  as  asserted  bj 
Mr.  Tamplin  and  others.  And,  to  sustain  this  hypothetical  view, 
supposed  evidence  of  the  fact  is  presented,  that  the  contortion  of 


182  Orthopmbia. 

the  spine  in  the  foetus  is  accompanied  with  strabismus,  club-foot, 
torticollis,  and  convulsive  appearances  of  the  face  and  other  spas- 
modic affections,  as  that  of  the  limbs,  and  even  epilepsy. 

Whatever  the  cause  may  be,  latent  influence  certainly  exists  that 
tends  to  this  abnormal  condition  in,  not  only  the  foetus,  but  chil- 
dren of  from  one  to  ten  years  of  age ;  as  we  have  had  such  cases  to 
treat  in  the  Hospital  for  the  Belief  of  the  Euptured  and  Crippled, 
and  the  most  careful  investigation  has  failed  to  give  satisfactory  in- 
formation even  as  to  the  probable  cause.  The  parents  state  that 
they  have  not  observed  from  the  birth  of  these  children  any  symp- 
toms of  convulsions  or  spasms  —  only  a  gradual  tendency  to  the 
contortion,  which  they  have  made  most  strenuous  efforts  to  correct 
by  opposing  position,  bandaging,  and  stiffened  corsets;  to  the  ap- 
parent infliction  of  pain  to  the  child  that  counteracted  all  their 
efforts. 

It  will  be  observed  that  in  most  cases  the  liver,  spleen,  and  mesen- 
teric glands  are  hypertrophied,  and  a  morbid  sensitiveness  to  press- 
ure in  the  concave  side  of  the  iliac  region,  indicating  some  internal 
lesion.  The  general  appearance  of  these  patients  indicates  a  feeble 
organization,  impaired  by  some  occult  disease  that  has  gradually 
developed  as  a  sequence  —  lateral  curvature  of  the  spine. 

The  prognosis  of  cure  in  these  cases  is  always  of  doubtful  con- 
sideration. The  contorted  condition  of  the  body  is  of  the  least  im- 
portance in  the  treatment  —  other  than  to  arrest  the  increasing  ten- 
dency to  deformity.  This  is,  in  some  cases,  very  embarrassing  to  the 
practitioner ;  as  it  is  attended  with  pain  and  actual  injury  to  the 
patient,  whose  morbidly  sensitive  condition  countervails  the  efforts 
that  may  be  made  to  sustain  the  body  by  steel  supports,  which,  if 
persevered  in,  in  some  cases,  tends  to  serious  impairment  of  the 
general  health  of  the  child.  All  firm  supporting  braces  under  such 
circumstances  are,  more  or  less,  inadmissible,  and  can  only  be  use- 
ful when  a  more  favorable  condition  of  health  is  obtained. 


NON-CIONGENITAL  LATERAL  CURVATURE  OP  THE  SPINE. 

Lateral  deviation  of  the  spine  becomes  most  frequently  observable 
in  girls  at  the  age  of  from  thirteen  to  eighteen,  and,  in  rare  instan- 
ces, in  boys.  This  is  one  of  the  pathological  conditions  of  the 
afflicted,  that  has  been,  through  the  indifference  of  medical  practi- 


LATERAL  Curvature  of  the  Spine.  183 

tioners,  generally  submitted  to  adventurous  treatment,  as  cases  in 
which  they  had  but  little  confidence  in  the  possibility  of  even  relief 
being  afforded.  This  apathy,  it  may  be  said,  has  existed  from  the 
days  of  Hippocrates  to  the  time  of  the  introduction  of  successful 
practical  tenotomy.  This  inestimable  discovery  in  practical  surgery 
of  restoring  to  normal  form  contortions  of  the  limbs,  incited  the 
efforts  of  many  of  the  most  eminent  surgeons  of  the  day  to  make 
the  novel  means  available  to  the  relief  of  nearly  every  description  of 
contortion  to  which  the  human  form  is  subject. 

There  are  three  conditions  of  the  aberrations  to  be  considered  in 
the  progress  of  this  ailment :  tortion,  lateral  curvature,  and  recur- 
vation of  the  spinal  column ;  the  latter  being  a  compensating  ten- 
dency to  the  maintenance  of  the  vertical  status  of  the  trunk  and 
head;  presenting,  in  some  cases,  several  distinct  curves  in  the 
spinal  column  from  near  the  base  of  the  lumbar  to  the  upper  por- 
tion of  the  cervical  vertebrae. 

The  antero-posterior  normal  curves  of  the  spinal  column,  invite 
very  special  consideration  in  relation  to  their  tendency  to  the  abnor- 
mal condition  of  lateral  curvature  of  the  spine.  We  consider  the 
primary  tendency  of  lateral  inclination  in  the  spinal  column,  to  be 
the  result  of  tortion  produced  by  a  pathological  condition  of  cer- 
tain muscles,  having  their  direction  of  force  obliquely  from  the 
hypochondriac  to  the  iliac  region  ;  which,  subsequently,  involves 
all  the  muscles  that  sustain  the  spinal  column  when  in  a  normal 
condition;  and  their  relation  of  sustaining  force  impaired,  is  in 
direct  ratio  to  the  contortion  resulting  in  the  shortening  of  the 
body. 

The  inferior  serratus  posticus  muscles  having  their  origin  from 
the  spinous  processes  of  the  three  last  dorsal  and  two  first  lumbar 
vertebrae  and  dividing  into  four  fleshy  divisions, —  passing  obliquely 
upward  and  attached  to  the  ninth,  tenth,  eleventh  and  twelfth  false 
ribs,  near  their  cartilages  ;  have  their  direction  of  contraction  most 
favorable  to  rotating  the  trunk,  and  of  exceeding  great  power  when 
contracting.  Their  action  is  to  depress  and  tend  to  approximate 
the  ribs  toward  the  crista  ilii ;  and  when  these  muscles  contract 
without  the  co-ordinate  counteracting  restriction  of  their  co-opera- 
tors, rotate  the  spinal  column  upon  its  vertical  axis,  which  is  indi- 
cated by  the  advancing  of  one  shoulder,  as  the  whole  spinal  column 
is  subjected  to  this  influence,  thus  determining  a  positive  diagnosis 
in  the  incipiency  of  the  ailment. 


184  Orthopjebia. 

The  external  and.  internal  oblique  muscles  of  the  abdomen  of  one 
side,  contribute  largely  —  when  acting  without  counteracting  force 
—  to  the  contortion,  by  their  oblique  direction  of  force  ;  tending  to 
rotat-e  the  spinal  column,  and  to  the  right  because  of  the  more 
active  tendency  and  inclination  of  that  side  of  the  body,  as  in 
writing  and  similar  occupations  requiring  an  advanced  position  to 
the  right  side. 

Direct  or  reflex  irritation  tending  to  abnormal  uterine  function 
in  the  growing  girl,  contorted  position,  or  whatever  may  tend  to 
the  impairment  of  normal  antagonism  of  the  muscles  described, 
and,  subsequently,  by  shortening  of  the  muscles  that  sustain  the 
normal  status  of  the  spinal  column,  in  ratio  of  their  retraction, 
increase  the  curves,  to  the  diminishing  of  the  stature.  Thus  it  will 
be  observed,  that  the  compensatory  curves  or  lateral  direction  are 
only  the  result  of  the  depressed  normal  curves  rotated  in  a  lateral 
direction. 


PATHOLOGICAL    COIS^DITION   TEXDIXG   TO    LATERAL   CURVATUEE. 

There  is  in  many  individuals  a  seeming  predisposition  to  lateral 
deviation  of  the  spine,  and  limited  to  certain  degrees  of  exaggera- 
tion—  in  young  women  especially — the  tendency  to  the  aberration 
being  most  apparent  during  their  menstrual  periods.  The  promi- 
nent hip  and  advanced  shoulder  will  then  be  perceptible  to  even  the 
casual  observer,  and  in  some  individuals  only  during  that  period  — 
the  patient  suffering  from  pain  in  the  side  and  back.  This  may  be 
considered  as  reflex  irritation  affecting  the  inferior  serratus  posticus, 
obliquus  externus,  and  internus  abdominus  muscles,  which  is  greatly 
increased  in  all  cases  where  the  patient  labors  under  painful  men- 
struation ;  the  pain  being  more  severe  in  one  hypogastric  region. 
This  incipient  stage  of  spinal  tortion  will  be  observed  more  especially 
when  the  individual  is  walking ;  and  young  women  thus  conditioned 
can  be  seen,  daily,  in  our  thronged  streets,  though  from  stratagem 
in  dress  (as  these  persons  are  usually  cognizant  of  their  contorted 
form)  the  prominent  hip  and  depressed  shoulder  may  not  be  notice- 
able, yet,  the  obliquity  of  their  personal  appearance  is  very  percep- 
tible and  cannot  be  readily  controlled  when  walking  —  the  depressed, 
advanced  shoulder  being  quite  apparent. 

Of  persons  thus  afQicted,  many  are  never  more  unfavorably  con- 


Lateral  Curvature  of  the  Spine.  185 

ditioned,  whilst  others,  from  various  inimical  causes  too  numerous 
to  mention,  in  this  limited  work,  and  upon  which  many  respectable 
volumes  have  been  written,  yield  progressively  to  the  most  exag- 
gerated contortion  of  the  body,  accompanied  with  pain  and  great 
inconvenience.  The  incipiency  of  lateral  curvature  of  the  spine 
most  frequently  presents  in  the  young  girl,  when  approaching  the 
catamenial  flow,  a  seeming  predisposing  cause,  and  thus  it  may  be 
assumed  that  the  female  is  rendered  more  subject  to  this  ailment 
than  the  other  sex.  Lateral  curvature  of  the  spine  is,  by  unfavora- 
ble influences,  as  that  of  local  irritation,  or  long-continued  position 
of  resting  on  one  leg,  induced  in  persons  even  to  the  age  of  forty 
years;  but,  after  the  age  of  twenty,  there  will  be  found  as  many 
males  as  females  thus  afflicted;  it  being  then,  in  more  than  a 
majority  of  cases,  the  sequence  of  organic  lesion  of  the  liver,  spleen, 
heart,  lungs,  or  kidney;  affecting  only  the  one  side;  inducing  a 
lateral  position  that  may  become  permanent ;  and,  in  some  instances, 
increasing  in  tendency,  but  rarely  to  the  same  extent  as  those  having 
the  earlier  impression. 

In  regard  to  these  internal  organic  lesions  Mr.  Barwell,  in  a  trea- 
tise on  the  causes  and  treatment  of  lateral  curvature  of  the  spine, 
published  in  London,  in  1868,  page  74,  says :  "  Causes  of  internal 
origin  assume  a  variety  of  shapes  from  the  gradual  long  curve  occu- 
pying all  or  nearly  all  of  the  dorsal  region  to  the  well  marked,  short 
and  sudden  aberration  of  two  or  three  vertebr£e  occurring  anywhere 
between  the  first  and  tenth.  These  latter,  particularly  if  they  be 
high,  are  generally  connected  with  tubercle  of  the  lung.  Pneu- 
monia induces,  as  a  rule,  the  low,  long  curve  which,  even  when  the 
functions  of  the  lung  have  been  restored,  continues  for  a  long 
time, —  perhaps  permanently.  Pleurisy  produces  several  forms  of 
curves,  but  chiefly  a  high  curve,  longer  and  less  sharp  than  the 
consumptive  curve."  This  eminent  and  experienced  practitioner 
also  says  in  regard  to  these  causes:  "  They  do  not  arise  from  contrac- 
tion on  the  diseased  side,  but  from  the  fact  that  when  any  portion 
of  the  lung  becomes  unfit  to  perform  its  office,  or,  when  disease 
renders  such  performance  painful,  the  rib,  or  ribs,  over  that  part  of 
the  organ  cease  to  move,  whilst  those  on  the  other  side  continue, 
under  the  action  of  the  serratus,  to  act  unopposed  upon  the  verte- 
brae and  twist  them  round."  With  this  view  of  the  etiology  of  the 
ailment  our  experience  is  in  accordance  with  the  statement  of  Mr. 
Barwell,  that  these  causes  affect  both  sexes,  children    and  adults 


186  Orthopjedia. 

equally  ;  and  also  that  the  primary  influence  of  the  catamenial 
period,  in  enfeebled  (3onstitutions,  gives  the  preponderance  of  cases 
to  girls  from  eleven  to  eighteen  years  of  age. 


DIAGlfOSIS    OF   LATERAL   CURVATUEE   OF   THE   SPIN"E. 

The  aberration  from  normal  curving  of  the  spine  to  that  of 
lateral  curvature  is  involved  in  three  conditions  : 

1st.  Tortion. 

2d.  A  single  lateral  curve. 

3d.  Compensatory  curves  that  sustain  an  equilibrium  or  vertical 
bearing  of  the  body. 

In  the  incipient  stage  of  this  pathological  change  in  the  spinal 
column  we  but  rarely  find  two  cases  presenting  similar  appear- 
ances, yet  certain  curves  are  more  apparent  than  others.  The 
patient  being  stripped  of  clothing  and  standing  at  ease  in  as 
erect  a  position  as  possible,  the  surgeon  standing  on  the  left,  will 
readily  observe  the  advanced  right  shoulder;  a  convexity  to  the 
right  above  and  to  the  left  below.  The  principal  curve  commonly 
occupies  the  dorsal  or  dorso-lumbar  region,  which  is  explained  by 
the  fact  that  the  centre  of  motion  of  the  vertebral  column,  and  of 
the  lateral  flexion  in  particular,  is  situated  at  the  point  of  junction 
of  the  dorsal  and  lumbar  regions,  and  is  due  to  the  anatomical  dis- 
position of  the  articulation  uniting  the  eleventh  and  twelfth  dorsal 
vertebrae.  The  natural  curve  in  the  lateral  movements  of  the  spine 
decreases  from  the  loins  upward,  and  so  perceptible  is  the  change 
from  a  normal  condition,  in  the  incipient  stage,  that  the  indications 
are  obscure  and  render  the  diagnosis  difficult. 

Tortion,  being  the  first  impairment,  advances  the  right  shoulder 
and  is  distinguishable  from  the  hurried  gait  of  the  individual  from 
the  obliquity  of  the  advancing  body.  When  this  condition  is  de- 
termined other  indications  are  always  present,  as  tortion  changes 
the  normal  curve  of  the  spinal  column  which  gives  prominence  to 
the  ribs  of  one  side  —  the  deviation,  however,  being  obscured  by  the 
muscles,  though  in  a  very  attenuated  person  a  single  curve  may  be 
detected.  Other  more  apparent  indications  present,  as  may  be  seen 
in  engraving  74. 


Lateral  Curvature  of  the  Spine. 


187 


Fig.  74.  The  hands  interlocked  in  front  of  the 

abdomen  will  present  a  closer  approxi- 
mation of  the  right  arm  to  the  body 
than  the  left,  and  an  increased  promi- 
nence of  the  apex  of  the  scapula  of  the 
same  side.  Also,  an  increased  elevation 
of  the  longissimus  dorsi  in  the  dorso- 
lumbar  region  of  the  left  side,  and  a  re- 
sultant cincture  of  the  right,  that  leaves 
a  comparatively  limited  angular  space 
between  the  arm  and  body.  This  pre- 
sents the  apparently  elevated  hip ;  one 
of  the  most  marked  indications  of  in- 
cipient lateral  curvature  of  the  spine. 

In  the  second  stage  of  spinal  flexion, 
exaggeration  of  form  increases  to  a  very 
perceptible  deviation  from  a  vertical 
line,  and  presents  a  more  widened  space 
between  the  body  and  the  arm  of  the  left 

side,  as  seen  in  the  following  engraving. 

Fig.  75  represents  the  second  stage  of  lateral  curvature  of  the 

spine,  in  which   there  is  as  yet  but  a  very  limited  change  in  the  form 

of  the  hips. 

These  two  stages  frequently  exist  with- 
out attracting  the  attention  of  the  as- 
sociates of  the  individual  thus  affected, 
and  the  ailment  advances  to  the  third 
stage,  being  then,  probably,  first  dis- 
covered by  the  dressmaker,  who  ob- 
serves the  unequal  formation  of  the 
hips  and  chest  in  the  attempt  to  fit  the 
dress.  This  unfortunate  oversight  often 
precludes  the  possibility  of  effecting  a 
perfect  cure ;  the  two  first  stages,  other 
circumstances  being  favorable,  are  sus- 
ceptible to  successful  treatment. 

In  the  third  stage  we  have  recur- 
vation or  the  compensating  curves 
very  marked.  The  spinal  column  is 
then  forced  into  opposite  directions  to 
the   sustainins^  of  the  vertical  bearing. 


Fifl.  75. 


188 


Orthopjedia. 


Fig.  76. 


By  this  adaptation  the  erect  position  of  the  person  is  maintained. 
As  soon  as  a  part  of  the  vertebral  colurn  deviates  from  a  perpen- 
dicular, another  portion  institutes  a  curve  in  an  opposite  direction; 
shortening  the  body,  and  causing  additional  curves.  For  this 
reason,  in  reality,  a  single  curve  never  exists;  more  commonly 
two  are  found  unaccompanied  by  a  third.  Three  are  very  com- 
mon, and  four  occasionally  met  with  as  seen  in  the  accompany- 
ing engraving. 

Here  we  have  four  curves.  The  first 
the  dorso-lumbar,  maintained  by  the 
sacro-lumbalis,  and  longissimus  dorsi ; 
central  curve,  the  same  muscles  with  the 
spinalis  and  semi-spin  ales  dorsi ;  and  the 
cervical  curve,  the  complexus  cervicalis 
ascendens,  and  trans versalis  colli.  In 
the  dorso-cervical  region,  two  curves,  in 
extraordinary  cases,  are  definable ;  and 
the  result  an  exaggerated  condition  of 
the  contortion,  from  the  eff'ort  to  main- 
tain the  head  in  an  erect  position.  See 
Nos.  1,  2,  3  and  4,  in  Fig.  76. 


TREATMENT  OF   LATERAL  CURVATURE  OP  THE  SPIN'E. 

It  is  the  general  opinion  of  medical  practitioners  that  lateral  cur- 
vature of  the  spine  is  less  amenable  to  treatment  than  contortions 
of  the  limbs.  This  impression  we  attribute  to  the  failure  to  dis- 
cover the  ailment  in  its  incipiency ;  and  that,  when  advice  is  sought, 
it  has  advanced  to  the  third  stage ;  requiring  much  practical  skill 
to  relieve  the  patient,  even  in  a  moderate  degree,  from  the  pain  and 
inconvenience  naturally  resulting  from  so  lamentable  a  con- 
dition. 

The  first  effort  should  be  to  obtain  a  satisfactory  diagnosis  of  the 
indications  that  present  in  the  abnormal  developments,  and  condi- 
tion of  health  of  the  patient;  and  to  ascertain  whether  any  inimi- 
cal influence  is  tending  to  the  increase  of  the  ailment;  such  as 
occupation  or  habits  of  unfavorable  position  of  the  body.  The 
treatment  should  consist  of  a  proper  regime  associatied  with  special 


Lateral  Curvature  of  the  Spine. 


189 


exercise  of  the  muscles  of  the  body.     The  latter  may  be  obtained 
most  readily  in  the  use  of  the  parallel  bars. 


Fig.  77. 


The  patient  being  relieved  of  all  clothing  that  would  in  the  least 
restrict  muscular  exercise  or  freedom,  and  having  entered  the  frame 
the  longitudinal  bars  should  be  elevated  so  as  to  only,  at  first,  per- 
mit the  person  to  sustain  the  upright  position  upon  the  extreme 
■ends  of  the  toes ;  the  body  and  lower  limbs  being,  as  nearly  as  pos- 
sible, suspended  by  the  vertical  support  of  the  arms  upon  the  bars. 
This  position  having  been  attained,  the  patient  should  then  be 
directed  to  flex  the  legs  to  a  right  angle  with  the  body,  and  to  keep 
up  an  alternate  extension  and  flexion  of  the  body  and  legs  until 
fatigue  gives  notice  of  the  necessity  of  rest,  when  a  suitable  elastic 
support  of  equal  elevating  force  should  be  applied  to  the  body  while 
in  the  suspended  position.  The  supporting  apparatus  we  have 
devised  for  the  treatment  of  the  first  stage  of  the  ailment  is  repre- 
sented in  Fig.  78. 

Fig.  78.  Eepresents  a  back  view  1,  a  steel  belt 

to  rest  upon  the  pelvis  ;  2,  a  front  plate 
of  thin  metal  covered  with  soft  material 
and  having  straps  attached  which 
enclose  the  steel  belt  above  the  hips  and 
support  the  pendant  portion  of  the 
abdomen ;  3,  shoulder  straps  to  be 
passed  over  the  shoulder  in  front, 
brought  back,  and  secured  to  studs  riv- 
eted into  upright  steel  bars  that  sup- 
port the  back  ;  4,  axilla  supports,  hav- 
ing free  movement  in  their  attachment 
to  curved,  horizontal  lever  bars,  with 
studs,  5  5,  on  each,  to  which  are  but- 


190  Or  thop^dia. 

toned  straps  fastened  to  wire  spring  clotli,  and.  by  which  elastic 
extension  is  made ;  6,  the  wire-spring  cloth  firmly  secured  to  the 
steel  belt,  1.  This  apparatus  affords  simply  elastic  lateral  exten- 
sion to  the  dorsal  muscles,  admitting  also  of  increasing  elastic 
force  that  can  be  adjusted  to  the  elevation  of  the  depressed 
shoulder.  By  this  means  the  enfeebled  muscles  are  assisted,  and 
an  equilibrium  of  action  established,  without,  in  the  least,  arrest- 
ing normal  expansion  of  the  chest,  being  a  most  admirable  ther- 
apeutic agent  in  the  treatment  of  incipient  cases  of  lateral 
curvation  of  the  spine. 

From  the  exercises  on  the  parallel  bars,  followed  by  the  appli- 
cation of  the  elastic  support,  the  patients  having  improved  in 
general  health,  in  ordinary  cases,  will  in  a  few  months  be  enabled 
to  maintain,  for  a  limited  time,  the  normal  jDOsition  of  their 
back  without  support.  When  this  improvement  has  been  attained, 
cold  sponging,  or  the  douche,  may  be  apjolied  to  the  back  once  a  day, 
a  most  salutary  means  of  perfecting  the  cure.  Persons  thus  pre- 
disposed must  avoid  all  sedentary  pursuits,  and  avail  themselves  of 
active,  out-of-door  exercises,  so  as  to  invigorate  the  muscular  system^ 
which,  when  improved  in  tone,  will  maintain  their  normal  integrity. 

Cases  of  lateral  curvature,  or  the  first  stage  of  contorted  spine, 
may  be  favorably  influenced  by  maintaining  an  appropriate  position,, 
which  can  be  obtained  by  having  a  chair  so  constructed  that  the 
child's  elbow,  of  the  contracted  side,  shall  rest  upon  an  arm  sus- 
tained upon  coiled  wire  springs,  of  sufficient  height  and  appropriate 
form,  tending  to  elevate  the  shoulder,  and  thus  extend  the  con- 
tracted muscles.  In  addition  to  the  elevating  arm,  the  seat  of  the- 
chair,  consisting  of  two  portions,  one  over  the  other,  that  will 
admit  of  being  separated  by  means  of  a  wedge  or  screws,  may  be 
arranged  so  as  to  elevate  one  side  or  the  other,  as  may  be  desired^ 
See  Fig.  79. 

This  is  a  valuable  device,  and  one  most  favorably  considered  by 
Mr.  Eichard  Barwell,  in  a  treatise  published  in  London,  in  1868,. 
who  states  therein,  page  110,  that,  ""When  the  patient  sits  on  thir- 
stool,  with  the  feet  stretched  out  in  front  so  that  they  do  not  influ- 
ence the  trunk,  and  when  the  end  on  the  convex  side  (of  the 
patient)  is  slowly  lifted,  one  observes  the  following  changes: 
Firstly,  and  previous  to  any  perceptible  change  in  the  lateral 
bend,  the  lumbar  vetebras  begin  to  relinquish  their  tortion  —  tO' 
untwist   themselves :    the   parts   on   the   convex   side  become  less 


Lateeal  Curvature  of  the  Spine. 


191 


'*';    ■  hard,  those  on  the  concave  side  more  so 

and  the  transverse  processes  sink  deeper 
—  are  not  so  evident;  the  lateral  inflex- 
ion then  also  becomes  affected,  and  in 
all  but  severe  cases  it  will  disappear." 
This  is  only  aiaxiliary,  however,  to  the 
treatment  in  this  class  of  ailments.  Con- 
stitutional, remedial  means  must  be  very 
carefully  prescribed  even  to  give  prom- 
ise of  relief;  and  spinal  supports,  when 
they  can  be  endured,  must  be  worn. 

The  first  and  most  important  con- 
sideration is  the  condition  of  the  pa- 
tient's health,  not  the  contortion,  which 
is  of  minor  importance  to  this,  and 
cannot  be  successfully  treated  whilst  the 
patient  is  laboring  under  the  pathologi- 
cal condition  that  induced  the  aberra- 
tion of  form.  The  skilled  practitioner 
in  medicine  is  the  most  competent  person  to  give  the  primary  relief. 
Judicious  regimen  and  auxiliary  therapeutical  means  may  be  made 
available  to  advantage;  as  that  of  calisthenic  exercises  and  sustain- 
ing support  to  the  spine.  Careful  avoidance  of  all  pursuits  requir- 
ing an  unfavorable  position  of  the  body.  The  practice  of  extend- 
ing the  body,  reclining  upon  the  back  upon  a  bench  or  any  firm 
plane  surfaced  support,  and  remaining  in  that  position  for  several 
hours  at  a  time,  the  head  not  raised  above  the  line  of  the  body, 
contributes  to  the  means  of  cure  ;  and,  as  before  stated,  the  body 
support  only  to  be  removed  or  loosened  when  taking  exercise  on 
the  parallel  bars. 

Electricity  in  the  advanced  stage  of  the  ailment  has,  in  our  ex- 
perience, been  of  no  benefit,  and  objectionable  as  a  therapeutic  agent, 
though  it  has  been  highly  recommended  by  some  writers  because  of 
its  tendency  to  maintain,  if  not  increase,  the  tensity  of  relaxed 
muscles  on  the  prominence  of  the  curves  on  either  side  of  the  back. 
However  carefully  it  may  be  applied,  there  is  great  difficulty  in  con- 
fining it  to  the  elongated  muscles ;  a  serious  objection  to  its  use  in 
all  cases  of  impaired  muscular  equilibrium.  The  spinal  support  to 
be  worn  in  the  advanced  stage  of  the  ailment,  is  required  to  encircle 
the  body  and  afford  decided  lateral  support  to  the  prominent  ribs. 


192 


ORTHOPyEBlA. 


It   will   bo   observed  that  "    -^~'"~~^      '^^  ^° 

lateral  pressure  is  obtained 
by  the  lacing  in  front,  and 
the  advanced  shoulder  is 
controlled  by  the  shoulder 
straps.  This  lateral  pres- 
sure on  the  protuberant 
ribs  and  advancing  shoulder, 
maintains  the  extension  of 
the  body  obtained  from  ex- 
ercise on  the  parallel  bars, 
by  the  lacings  of  the  textile 
fabric  of  the  fronts,  which 
only  cover  about  one-third 
of  the  circumference  of  the 
chest.  The  steel  bars  and 
plate,  restrict  and  tend  to  restore  to  normal  form  the  salient  parts, 
thus  tendin*-  to  the  unfolding  of  the  heavy  encasement,  and  giv- 
ing freedom  to  the  lungs.  This  gives  relief  from  pain  in  the  side 
and  chest,  and  impeded  respiration.  The  patients  will,  in  nearly 
every  case,  express  great  satisfaction  in  the  relief  that  has  been 
afforded  them,  and  tliis  relief  alone  is  commensurate  with  the  wear- 
ing of  this  support  in  the  confirmed  cases  of  the  ailment. 

Xo  objection  can  be  offered  to  the  support,  as  to  the  wearing  of 
corsets,  as  it  cannot  compress  the  chest  because  of  the  irregular 
contour  that  limits  the  pressure. 


TEXOTOMY   AS   A   MEAXS    OF   CURE. 

This  adventurous  procedure  of  dividing  the  spinal  muscles  was 
introduced  by  the  eminent  orthopgedist,  Jules  Guerin,  of  Paris,  and 
is  one,  we  believe  to  be,  of  no  advantage  in  the  treatment  of  con- 
firmed cases.  And,  as  to  the  first  and  second  stages  of  the  ailment, 
they  are  as  readily  cured  without  tenotomy  as  with,  being  so  deter- 
mined by  the  indubitable  authority  of  a  committee  of  eminent 
surgeons.  Carefully  conducted  exercise  tending  to  extension,  and 
maintained  by  suitably  devised  apparatus,  is  required  if  the  tense 
muscular  fascicula  have  been  divided,  and,  as  it  is  impossible  to  di- 
vide all  the  muscles  in  the  compensating  curves,  there  is  but  a  very 
little  compensation  afforded  in  the  division  of  a  few  tense  bands. 


Lateral  Curvature  of  the  SpiiXe.  193 

The  patieut  is  placed  in  such  a  position  as  will  render  the  retrac- 
ted muscular  fasciculus  (as  it  is  the  hardest  of  the  fascicula  that 
present)  most  tense  —  usually  laid  upon  a  table  or  bed,  back  up- 
ward, and  directed  to  raise  the  head,  which  action  brings  the  dorsal 
muscles  into  play,  and  the  retracted  fibres  are  made  tense.  A  fold 
of  skin  is  then  pinched  up  at  the  outer  edge  of  the  extended  fas- 
ciculus, and  a  puncture  being  made,  a  strong  tenotomy  knife  is  in- 
troduced flatwise  at  its  base,  at  a  point  which  will  recede  to  the  dis- 
tance of  an  inch  from  the  external  border  of  the  muscle.  The 
knife  being  turned  upon  the  mass,  the  fibres  are  divided  by  a  slow 
sawing  movement. 

The  contraction,  we  are  informed,  in  some  cases,  after  six  or  eight 
months  from  the  time  of  the  division  (having  been  subject,  in  the 
meantime,  to  mechanical  treatment),  becomes  again  so  decided  as 
to  require  severing  once  more  to  complete  the  treatment. 

Guerin,  of  Paris,  was  the  first  to  attempt  dorsal  myotomy  in  the 
treatment  of  lateral  curvature  of  the  spine,  and  to  greatly  extol  the 
practice;  thus  inviting  the  attention  of  members  of  the  Academie 
de  M^decin,  in  Paris,  to  the  investigation  of  its  merits. 

On  the  12th  of  November,  1844,  after  a  most  excited  discussion 
in  the  Academy,  the  matter  was  referred  to  a  committee.  Velpeau . 
and  Eoux,  of  this  committee,  in  due  time,  read  a  most  elaborate  re- 
port upon  the  subject,  having  carefully  investigated  the  matter  in 
all  its  beai'ings.  This  extraordinary  scientific  investigation  resulted 
in  an  expose  of  the  actual  anatomical  deviations,  tending  to  the 
true  pathological  indications  to  be  met  by  treatment,  which  has 
since  been  carefully  considered  and  more  fully  determined,  and  has 
resulted  most  favorably  to  this  afflicted  class,  by  introducing  a  more 
scientific  treatment. 

Probably  one  of  the  most  serious  difficulties  to  be  encountered  in 
the  treatment  of  lateral  curvature  of  the  spine,  in  the  advanced 
stage  of  the  ailment,  is  indiscretion  on  the  part  of  the  patient,  in 
failing  to  perseveringly  pursue  the  treatment.  The  patient  hav- 
ing been  afflicted  for  several  years,  and  approaching  the  age 
for  introduction  into  society,  the  temptation  to  indulge  in  social 
enjoyment  is  so  strong  that  temerity  often  gets  the  ascendancy  of 
prudence,  and  all  restraint  is  placed  in  abeyance.  This  indulgence 
is  so  frequent  as  to  seriously  interfere  with  the  treatment,  and 
is  eventually  abandoned  because  of  the  lack  of  apparent  improve- 
ment. 


194  Or  thop^jDIa  . 

The  regimen  to  be  enforced  is  not  essentially  different  from  that 
of  the  first  stage.  The  frequent  use  of  the  parallel  bars,  and  con- 
stant wearing  of  the  spinal  supporter,  day  and  night,  contribute 
most  largely  to  the  cure. 


TOETICOLLIS. 

There  are  various  causes  that  tend  to  this  distortion,  mainly  the 
result  of  the  retraction  of  the  sterno-cleido  mastoideus  muscle. 
Bouvier  speaks  of  a  condition  of  wry-neck  caused  by  inflammation 
of  the  fibrous  tissue  of  the  cervical  vertebras,  and  terms  it  articular 
torticollis.  It  is  either  acute  or  chronic.  Contortion  results  from 
long-continaed  effort  of  the  patient  to  relieve  the  tense  and  painful 
ligaments  by  displacing  them  in  the  direction  which  the  head  ulti- 
mately retains  ;  abscesses  and  cicatrices  in  the  cervical  region ; 
tumors  and  glandular  engorgements ;  or,  paralysis  of  the  muscles 
of  one  side  —  the  head  yielding  to  the  same  for  want  of  antago- 
nizing force. 

A  remarkable  feature  in  this  ailment  (as  in  that  of  lateral  curva- 
ture of  the  spine)  is,  that  the  deviation  is  most  frequent  to  the  right 
side. 

The  appearance  of  the  patient  is  that  of  having  the  head  rotated, 
and  depressed  upon  the  shoulder  of  the  affected  side,  the  chin,  ap- 
parently, elevated  on  the  extended  side,  and  the  whole  features  of 
the  face  changed.  In  the  region  of  the  sterno-cleido  mastoid  muscle 
a  firm  cord  is  felt,  which  is  made  more  prominent  if  force  is  applied 
in  a  direction  opposite  to  its  action.  A  very  common  cause  of  this 
deformity  is  paralysis,  which  is  readily  diagnosed  by  the  lifting  of 
the  head  with  the  hands.  The  next  most  common  is  inflammation 
of  the  cervical  fascia  from  exposure  to  cold  drafts  of  air  ;  the  fierce 
pain  retaining  the  head  in  a  contorted  position.  Extensive  burns 
tend  largely  to  the  production  of  wry-neck,  and  are  actually  irre- 
sistible in  the  cicatrization  of  the  denuded  surface. 


TREATMENT   OF   TORTICOLLIS. 

In  torticollis,  except  in  the  incipient  stage,  the  whole  vertebral 
column  becomes  more  or  less  implicated,  and  requires  a  somewhat 


Lateral  Curvature  of  the  Spine.  195 

similar  treatment  to  that  of  lateral  curvation  of  the  spine,  namely, 
extension  support,  as  in  that  of  the  second  stage  of  lateral  curva- 
tion. To  the  spinal  supporter  (Fig.  81)  is  attached  a  steel  bar  ex- 
tending upwards  and  over  the  top  of  the  head,  to  which  is  attached 
a  cross-piece  of  three  inches,  curved  to  conform  to  the  head,  and 
made  to  rotate  upon  a  swivel.  To  this  cross-piece  supporting  straps 
are  attached  to  elevate  the  chin ;  and,  with  the  assistance  of  a  sup- 
porting strap  to  the  occiput,  this  tends  to  elevate  the  head  and  ex- 
tend the  neck.  This  form  of  apparatus  is  also  useful  in  the  treat- 
ment of  caries  of  the  cervical  vertebrae,  and  is  represented  in  the 
chapter  in  which  that  ailment  is  treated. 

Manipulation  of  the  contracted  muscles  is  of  much  value  in  the 
treatment,  and,  if  from  a  paralytic  seizure  of  the  inuscles,  the  appli- 
cation of  strychnine  ointment,  twelve  grains  to  the  ounce.  Elec- 
tricity, also,  carefully  applied  to  the  relaxed  muscles  will  restore 
their  contractile  ability.  The  main  reliance,  however,  is  in  constant 
extension  of  the  neck.  The  division  of  the  contracted  muscle  is 
only  a  very  limited  auxiliary  to  restoration  of  the  normal  condition ; 
but  by  patient  perseverance  the  ailment  is  curable  by  means  of 
properly  constructed  mechanical  support. 


DIVISIO]Sr    OF   THE    STERJiTO-CLEIDO-MASTOIDEUS    MUSCLE. 

It  is  nearly  two  centuries  since  the  stern o-cleido-mastoid 
was  first  severed  for  the  relief  of  wry  neck.  The  operation 
consisted  in  first  dissecting  out  the  muscle,  then  dividing  it  on 
a  grooved  director.  This  mode  of  operating  is  at  the  present 
day  practiced  by  some  surgeons  in  preference  to  the  subcutaneous, 
apprehending  danger  of  wounding  some  of  the  large  blood-vessels 
of  the  neck. 

The  subcutaneous  method  is  now  the  most  commonly  adopted, 
being  the  least  painful,  and,  with  ordinary  care,  not  in  the  least  dan- 
gerous ;  each  surgeon  differing  slightly  from  others  both  in  the 
management  of  his  patient,  and  in  the  division  of  the  muscle.  A 
common  procedure  is  to  have  the  patient  seated,  the  head  thrown 
back  and  to  the  side  opposite  the  contracted  muscles,  and  so  held 
by  an  assistant,  while  a  second  assistant  depresses  the  shoulder 
of  the  affected  side.  This  arrangement  renders  the  muscle  prom- 
inent.     The    operator   then   lifts    the    muscle    with    his     thumb 


196 


Orthop^^dta. 


and  finger,  and  passes  beneath  it  a  small  curved  tenotome  at  a  short 
distance  above  the  sternal  origin.  When  the  point  is  felt  beneath 
the  skin  on  the  opposite  side,  the  knife  is  made  to  slowly  and  care- 
fully divide  the  muscle  by  a  slow  movement.  As  soon  as  the 
knife  is  withdrawn,  the  blood  should  be  pressed  out,  and  the  puncture 
closed  with  adhesive  plaster.  A  compress  and  roller  complete  the 
dressing  ;  and  special  attention  must  then  be  given  to  diet  and  repose. 
The  wound  commonly  heals  by  the  third  day,  when  the  supporter 
and  extension  bar  should  be  applied,  and  the  patient  permitted  to 
sit  up,  and,  in  two  weeks'  time,  to  walk  about. 

The  section  of  the  sternal  origin  of  the  muscle  suffices  in  some 
cases,  but  it  is  quite  as  well  to  divide  both  fascicula.  It  is  usual  to 
sever  the  most  prominent  of  the  two  if  intending  to  divide  but 
one,  to  test  the  tenseness  of  the  other,  and  to  wait  a  few  days  before 
dividing  the  other.     This  procedure  is  suggested  by  Bonnet. 

The  following  engraving  is  a  back  ^dew  of  spinal  brace  and  head 
support,  to  extend  and  straighten  the  neck,  in  the  treatment  of 
torticallis. 


Fig.  81. 


CHAPTER    VIII. 

RACHITIS. 

Osseous  growth  and  development  of  cartilage  cells  the  first  indication  of  ita 
presence. —  Dr.  Rindfleisch's  description  of  symptoms. —  Kolliker  the  first  to 
observe  the  transition  process  of  cartilage  to  bone. —  Peculiar  formation  of  the 
joints  in  rachitic  subjects. —  "Double- jointed"  persons. —  Anterio-posterior  cur- 
vature of  the  spine  a  common  indication  of  "rickets."  —  Usually  confined  to 
children  under  one  year  old. —  Treatment  of  anterio-posterior  curvature. —  More 
decided  treatment,  with  mechanical  support,  necessary  for  children  of  advanced 
age. —  Cod-liver  oil  as  a  curative  medium. —  Bismuth  an  effective  remedy. — 
Projecting  sternum. —  Dapuytren  on  its  origin. —  Description  of  the  patient's 
condition. —  The  effect  of  the  chest,  impairment  on  the  lungs. —  Treatment  of 
projecting  sternum. —  Truss  for  projecting  breast. —  Genu  extorsium,  or  bow- 
legs.—  Often  cured  without  instrumental  aid. —  General  treatment  of  genu  ex- 
torsium.—  Various  apparatus. — Genu  valgum,  or  knock-knees. —  Diagnosis  in 
children. —  Mr.  Tamplin's  theory  of  the  deformity. —  Treatment  of  genu  val- 
gum.—  Mechanical  support  the  best  remedy. — Apparatus. —  Efforts  at  walking 
of  great  utility  in  treatment. 


Eacliitis,  the  abnormal  condition  of  the  formative  process  in  the 
growth  of  bone,  tends  to  great  aberration  of  the  normal  form  of 
the  skeleton,  and  as  a  pathological  condition  invites  special  investi- 
gation from  the  practitioner  in  medicine.  The  first  impairment 
presents  in  the  osseous  growth  and  development  of  the  cartilage 
cells  by  an  increased  number  of  divisions.  Dr.  Eindfleisch  states,  in 
his  valuable  text-book  of  Pathological  Histology,  that  from  ten  to 
twenty  and  more  layers  of  cartilage  cells  unite  simultaneously  upon 
the  proliferating  process,  and  these  again  divide,  forming  cell  groups 
of  thirty  to  forty  elements,  which  are  placed  in  long  drawn  columns 
somewhat  bent  and  compressed,  here  and  there,  by  the  material 
flattening  vertically  toward  the  surface  of  the  bone,  while  upon  the 
normal  bone  we  scarcely  observe  the  proliferating  zone  of  the  carti- 
lage with  the  nalced  eye,  except  as  but  an  exceedingly  narrow,  red- 
dish grey  stripe  ;   upon  the  rachitic  bones,  it  expands  as  a  broad. 


198  Orthop^bia. 

translucent  grey,  and  very  safe  cushion  between  the  cartilage  on 
the  one  side,  and  the  completed  osseous  structure  upon  the  other. 

That  which  takes  place  in  the  cartilage  is  repeated  in  the  perios- 
teum. The  young,  vascular,  germinal  tissue  which  is  produced  by 
the  periosteum  at  its  surface  lying  toward  the  bone,  under  normal 
circumstances,  only  presents  a  thin  stratum  that  is  scarcely  percep- 
tible to  the  naked  eye.  The  rapidity  with  which  it,  though  just 
produced,  is  transformed  into  bone  does  not  permit  a  large  accumu- 
lation to  take  place.  It  is  otherwise  in  rachitis ;  under  the  influ- 
ence of  the  morbid  process  this  transition  substance  often  accumu- 
lates in  very  great  layers  of  a  line  in  height.  The  great  abundance 
of  the  thin-walled  and  wide  capillaries  occasions  the  coloring  of 
the  young  connective  tissue.  The  deposit,  as  a  rule,  is  drawn  in 
the  form  of  a  broad,  flat,  bed-like  elevation  over  the  surface  of  the 
bone.  Upon  the  flat  bones  of  the  cranium  they  are  sharply  circum- 
scribed, which  is  not  the  case,  to  such  an  extent,  at  the  extremities. 
Kolliker  Avas  the  first  to  observe  the  transition  process  of  cartilage 
to  bone  in  rachitic  subjects.  The  cartilaginous  bone  consists  of 
largely  separate  medullary  spaces  which  are  considered  by  Eind- 
fleisch  as  not  to  be  regarded  as  calcified  cartilage,  but  as  osseous 
tissue ;  and  he  further  remarks  :  ''  It  is  true  we  cannot  doubt  that, 
excepting  the  impregnation  with  lime  salts,  only  a  very  moderate 
change  of  position  of  the  single  cells  has  led  to  the  transformation 
of  the  proliferated  cartilage  into  the  texture  in  question." 

The  amount  of  calcification  may  equal  the  normal  quantity  in  the 
formation  of  bone,  but  in  rachitis  it  is  distributed  over  a  very  much 
larger  space  than  in  normal  circumstances,  leaving  the  osseous  tuber- 
cle very  thin  and  the  transformation  of  the  sub-periosteal  exuda- 
tion in  an  exceedingly  loose,  vascular  osteophyte,  covering  the  bone 
in  an  undue  thickness  and  larger  than  in  the  normal  condition  — 
compact  bony  substance  being  retarded  for  an  indefinite  time. 

Eachitic  aberration  of  the  normal  form  of  the  bones  of  the  skele- 
ton is  supposed  to  arise  from  mechanical  force,  and  mainly  from  the 
broad  layers  of  the  proliferated  cartilaginous  tissue  which  passes 
in  between  the  epiphyses  and  the  diaphyses  of  long  bones,  swelling 
them  out  laterally  and  forming  roundish  rolls  surrounding  the  hone. 
In  this  peculiar  formation  of  the  joints  in  rachitic  subjects, 
they  are  said  to  be  "double  jointed" — articuU  duplicati.  And  the 
swelling  of  the  collective  costal  cartilages  at  their  points  of  contact 
with  the  bone  is  termed  "rachitic  garland,"  and  presents  in  the 


Rachitis.  199 

articulations  of  the  ribs,  tending  to  what  is  known  as  "chicken 
breast" — pectus  gallinaceum,  the  sides  of  the  chest  being  drawn 
inwards  by  respiration.  Deformities  of  the  pelvis  are  attributable 
to  the  great  mobility  of  the  cartilages  of  the  synchondroses  sacro- 
iliacse.  The  sacrum,  under  the  weight  of  the  head,  trunk  and  arms, 
is  pressed  down  upon  the  yielding  synchondroses,  forcing  the  pro- 
montory of  the  sacrum,  forward  into  the  pelvic  strait ;  narrowing 
it  from  above,  and  tending  to  the  kidney  shaped  configuration. 

To  the  abnormal  periosteal  growth  may,  principall}',  be  attributed 
the  curvatures  and  fractures  of  the  shafts  of  the  long  bones.  The 
growth  of  the  bone  in  thickness,  the  continued  opposition  of  com- 
pact substance  at  the  periphery  is  constantly  and  everywhere  accom- 
panied by  resorption  of  the  compact  substance  at  the  inner  surface 
toward  the  medullary  cavity, —  a  resorption  which  keeps  pace  with 
the  opposition,  and  which,  also,  does  not  stand  still  during  the 
rachitic  process.  The  rachitic  condition  interrupts  the  peripheral 
opposition  of  the  compact  substance  ;  the  consequence  is  a  decrease 
of  thickness  of  the  already  thin  shaft,  and  which  is  not  sustained  by 
the  osteophytic  layers.  The  result  is  that  the  bones  bend,  and 
often  break,  producing  great  deformity,  and  lessening  the  stature 
from  curvature  of  the  bones  of  the  legs. 

Anterio-posterior  curvature  of  the  spine  is  a  very  common  indi- 
cation of  rickets, —  a  uniform  curving  of  the  spinal  column  pos- 
teriorly from  the  cervical  to  the  last  lumbar  vertebrae;  the  entire 
spine  being  implicated  in  the  aberration. 

The  ailment  is  most  commonly  confined  to  children  under  the 
age  of  twelve  months,  laboring  under  constitutional  debility,  and  to 
failure  of  the  dorsal  muscles  to  support  the  spinal  column.  The 
weight  of  the  head  and  upper  extremities  inclining  forward  makes 
an  undue  pressure  upon  the  anterior  portion  of  the  inter-vertebral 
substance,  tending  to  elongate  the  posterior  ligaments  of  the  spine. 
In  adults,  this  becomes  a  confirmed  condition  and  the  spinal  column 
so  fixed  as  to  limit  the  head  to  such  a  dependent  condition  as  to 
entirely  deprive  the  individual  of  the  privilege  of  looking  upward. 
These,  however,  are  very  rare  cases,  commonly  the  sequence  of 
inflammation  that  has  induced  permanent  contraction  of  the  abnor- 
mal muscles.  A  strumous  diathesis  predisposes  to  this  ailment  ia 
adults.  In  children  we  do  not  know  of  a  case  in  which  this  form 
of  curved  spine  has  become  a  permanent  deformity. 

In  this  ailment,  a  seeming  concomitant  of   struma,  the  patient 


200  Orthop^dta. 

presents  a  pallid  and  anxious  countenance,  attenuated  limbs,  greatly 
enlarged  joints,  a  voracious  appetite,  tumid  abdomen,  symptomatic 
of  mesenteric  disease,  the  alvine  evacuations  clay-colored,  the  inter- 
vertebral is  more  or  less  absorbed  from  undue  compression  forward; 
the  ribs  are  prominent  and  project  posteriorly  more  than  is  natural, 
and  the  scapula  becomes  raised  and  appears,  upon  examination,  to 
be  separated  from  the  thorax.  The  head  and  neck  appear  to  be 
sunk  between  the  shoulders,  and,  on  examination  of  the  spine,  the 
processes  will  be  found  very  prominent, — more  especially  in  the  lower 
dorsal  region;  presenting  to  the  inexjDerienced  practitioner  an  em- 
barrassing aspect  as  to  a  correct  diagnosis  and  one  that  has  been 
mistaken  for  caries,  commonly  known  as  Pott's  disease  of  the 
vertebra. 


TREATMENT  OF   ANTERIO-POSTERIOR   CURVATURE. 

Infants  of  about  six  months  of  age,  and  dependent  on  their 
mothers'  breast  for  nourishment,  should  be  given  a  teaspoonful  of 
beef  tea  once  or  tAvice  daily.  As  a  medicine,  we  have  found  the 
sub-nitrate  of  bismuth  to  be  the  most  remedial  in  tendency,  if  con- 
tinued for  months,  of  any  other  within  our  knowledge  —  three  grains 
of  bismuth  rubbed  up  with  gum  acacia,  and  given  morning,  noon 
and  night.  The  body  should  be  encircled  with  a  flannel  belt  from 
arm-pits  to  hips,  and  firmly  secured;  making  atmospheric  exposure 
available  as  much  as  prudence  will  allow,  and  close,  hot  rooms  care- 
fully avoided.  The  child's  body  and  limbs  should  be  frequently  bathed 
with  a  wet  sponge,  and  chafed  dry  with  the  warm  hand,  and,  if  before 
an  exposed  fire,  so  much  the  better.  For  bathing,  spirits  of  any 
kind  should  be  rejected  as  pernicious,  the  evaporization  robbing  the 
child  of  its  wonted  normal  heat.  The  same  may  be  said  of  its  use 
upon  delicate  adults.  Older  children  require  a  more  decided  treat- 
ment, as  that  of  bitter  tonics,  an  increase  in  the  dose  of  bismuth, 
and  a  liberal  diet  carefully  limited  to  stated  periods.  Mechanical 
support  will  also  be  required  in  these  advanced  cases,  as  that  of  the 
spine  and  head  supporter  used  in  the  treatment  of  caries  of  the 
cervical  vertebrae. 

The  patient,  when  in  bed,  must  dispense  with  the  use  of  a  pillow, 
and  make  efforts  to  recline  upon  the  back.  This  will,  at  first,  be 
both  painful  and  difficult,  but  after  a  time,  with  perseverance,  the 


Rachitis.  201 

desired  object  will  be  attained  without  inconvenience,  and  greatly 
to  the  patient's  benefit.  This  treatment  applies  to  all  rachitic  ail- 
ments. Cod  liver  oil  has  been  greatly  extolled  as  a  valuable  medicine 
in  the  treatment  of  rickets  ;  German  and  French  physicians  consider 
it  as  the  most  reliable  in  the  treatment  of  the  ailment.  Our  ex- 
perience has  not  been  so  favorable,  having,  even  in  small  doses 
given  to  patients,  discovered  the  undigested  oil  in  the  alvine  evacua- 
tions. Bismuth,  in  a  measure,  corrects  this  tendency,  but  serves  an 
equally  efi&cacious  purpose  Avhen  administered  with  a  nutritious 
diet,  as  the  promotion  of  the  digestive  process  appears  to  be  the 
most  certain  means  of  cure. 


PROJECTING  STERNUM. 

This  is  a  very  common  ailment,  tending  to  serious  impairment  of 
the  general  health  of  the  individual  thus  afflicted,  from  its  limiting 
the  capacity  of  the  thorax  by  lateral  pressure.  Dupuytren  advances 
the  theory,  that  it  is  the  sequence  of  deficient  stamina  ;  the  offspring 
of  lymphatic,  scrofulous  or  rachitic  people,  dwelling  in  low,  cold  and 
damp  places,  and  brought  up  on  unsubstantial  food.  The  deformity 
is,  m  some  cases,  congenital;  in  others,  it  occurs  during  childhood,  or 
later.  Dr.  Copeland  states  that  his  experience  leads  him  to  believe 
that  it  generally  comes  on  gradually  after  birth,  owing  to  deficient 
inflation  and  development  of  the  lungs,  arising  from  weakness  of 
the  muscles  of  inspiration  and  the  flexibility  of  the  ribs  at  the  time 
of  birth.  He,  also,  says  that,  in  cases  of  this  descriiDtion,  the  vital 
energy  of  the  lungs  is  insufficient  for  their  healthy  action,  and  the 
respiratory  mechanism  unable  to  accomplish  their  full  expansion 
or  sustain  the  continued  pressure  of  the  atmosphere,  before  which 
the  soft  and  imperfectly  formed  thoracic  parietes  gradually  yield. 
And  that  it  has  appeared  to  him  very  frequently,  to  be  greatly  in- 
creased, if  not  occasioned,  subsequent  to  birth,  by  the  very  com- 
mon practice  among  nurses  of  lifting  a  child  by  pressing  the  palms 
of  the  hands  on  the  sides  of  the  chest  immediately  under  the  arm- 
pits. That  both  of  these  most  eminent  gentlemen,  in  their  profes- 
sioii,  are  correct  in  their  views  as  to  the  predisposing  tendency  to  the 
aberration,  is  most  rational,  and  agree  perfectly  with  our  own  expeii- 
ence.     The  condition  of  the  patient  is  as  follows :     The  sides  of  the 


202 


Ortrop^dia. 


chest  are  very  much  flattened,  one  side  sometimes  more  than  the 
other ;  the  ribs  occasionally  appear  as  if  straightened,  and  the  sides 
form   an    acute   angle,  one  with  the  other,  the  ^. 

whole  serving  to  give  to  the  sternum,  undue 
prominence,  which  deformity  is  known  as  "pigeon 
breast."     See  Fig.  82. 

The  unfavorable  condition  of  a  chest  thus  con- 
tracted must  seriously  impair  the  functions  of 
the  lungs  and  the  impairment  is  in  ratio  to  the 
diminished  capacity  of  the  chest.  From  the 
depression  of  the  sides  of  the  chest  the  heart's 
action  is  embarrassed,  and  is  observable,  strongly 
pulsating  against  the  ribs;  the  circulation  tur- 
bid, the  breathing  quick  and  often  difficult, 
being  performed  through  the  moath,  a  wheez- 
ing, and  short,  dry  cough ;  the  nostrils  ob- 
structed by  enlarged  tonsils,  an  almost  con- 
stant accompaniment  in  this  ailment,  more 
clearly  defining  the  primary  cause  of  the  de- 
formity —  constitutional  deficiency,  a  true  rachitic  condition. 


TREATMENT   OF    PROJECTHiTG   STERNUM. 

Again  we  must  refer  the  constitutional  treatment  to  the  skilful 
practitioners  in  medicine,  as  it  is  wholly  unnecessary  to  even  hint  at 
a  treatment  that  is  already  familiar  to  them.  Not  that  we  would 
intimate  any  incapacity  on  our  part  of  presenting  a  judicious  course 
of  treatment,  but  that  we  consider  it  would  be  presumptuous,  and 
digressing  from  the  tenor  of  this  work,  which  is  mainly  intended 
to  introduce  therapeutic  agents  not  in  common  use  as  auxiliary  to 
the  relief  of  resultant  deformity,  such  as  lateral  curvature  of  the 
spine  and  projecting  sternum,  the  sequence  of  enfeebled  organic 
functions. 

It  is,  however,  important  to  consider  the  influence  of  the  defor- 
mity upon  the  impaired  organs  and  the  interference  in  their  func- 
tions tending  to  the  impairment  of  the  general  health  of  the  patient. 
It  is  reasonable  to  suppose  that  a  great  compressing  cover  like  this, 


Rachitis.  203 

oppressing  the  centre  and  source  of  the  circulatory  and  respiratory 
system,  should  produce  an  infinity  of  functional  derangements. 
Hence,  to  the  relief  of  the  patient,  an  efibrt  must  be  made,  in  the 
incipient  stage  of  the  ailment,  to  arrest  and  prevent  an  increase  of 
the  deformity,  and,  in  established  cases,  to  overcome  the  abnormal 
condition  by  whatever  means  the  practitioner  may  consider  the  most 
favorable.  Mechanical  appliances  are  objected  to  by  many  surgeons 
for  various  fancied  reasons.  Our  experience  impresses  us  favorably 
toward  their  use,  as  we  have  found  them  to  be  effectual  in  restoring 
the  chest  to  normal  form,  in  cases  of  long  standing,  and  patients 
are  invariably  benefited  by  their  application.  It  is  to  be  regretted 
that  improperly  constructed  apparatus  should  have  tended  to  dis- 
courage their  use,  and  this  is  wholly  the  fault  of  the  surgeon  be- 
cause of  his  reliance  upon  the  instrument-maker. 

The  construction  of  more  skilfully  devised  surgico-mechanical 
appliances  should  be  within  his  sphere  of  professional  knowledge, 
but  is  too  frequently  referred  to  the  mechanician. 

Fig.  83  represents  our  truss  for  projecting  breast.     A  semi-circular 
Fig.  83.  steel  spring,  having  attached  to  either  end 

cushioned  plates;  to  the  back  a  circular 
pad,  and  to  the  front  an  oblong  pad  which 
is  slightly  concave,  to  coaptate  with  the 
sternum ;  the  back  of  this  pad  having 
two  studs  at  suitable  distance  to  receive  the  encircling  straps  that 
retain  the  truss  and  pads  m  situ  when  properly  applied.  By  means 
of  this  apparatus  we  obtain  elastic  compression  of  continued  force 
concentrated  upon  the  projecting  sternum  from  counter-pressure  on 
the  back.  The  elasticity  of  the  encircling  belt  and  spring  admits 
of  lateral  expansion  of  the  chest,  the  principal  force  being  concen- 
trated upon  the  two  extremities  of  the  steel  springs,  and  their  tend- 
ing approximation  being  resisted  by  the  anterio-posterior  extension 
of  the  yielding  body. 

The  eminent  Dupuytren's  practice  was  as  follows:*  ^"'placing 
the  child  sideways  and  the  hand,  or  knee,  against  his  back,  or,  still 
better,  his  back  against  the  wall,  and  placing  the  palm  of  the  other 
hand  upon  the  most  projecting  part  of  the  sternum,  and  in  pressing 
or  pushing  the  anterior  part  of  the  chest  toward  the  posterior  part 
by  alternate  movements,  which,  after  some  days  practice,  accords  so 
well  with  the  movements  of  respiration,  that  the  little  patients  and 

*  "  Repertoire  d' Anatomic,  V.  p.  198. 


204  OrthopjEbia. 

those  wlio  exercise  the  pressure,  soon  learn  to  exercise  it  during  the 
time  of  expiration  and  to  suspend  it,  so  as  to  alloAV  the  breast  to 
develop  itself  during  the  movement  of  inspiration.  During  these 
movements,  a  souud  is  heard  similar  to  that  made  by  the  air  in 
alternately  entering  and  escaping  from  a  bellows. 

"■  I  have  often  attentively  observed  the  immediate  effects  of  this 
exercise.  Their  effects  are  a  flattening  of  the  projection  of  the  ster- 
num, a  greater  or  less  tendency  outward  of  the  ribs,  the  momentary 
return  of  the  chest  to  a  more  natural  shape,  respiration  much 
more  strong  and  perfect  than  in  general,  and,  when  the  pressure  is 
removed,  the  immediate  return  of  the  parts  to  their  ordinary  state 
accompanied  with  a  strong  inspiration. 

"  These  pressures  should  be  repeated  ten  times  —  a  hundred  times 
a  day,  if  it  were  possible,  and  continued  for  several  minutes  each 
time  ;  their  efficacy  will  be  in  proportion  to  their  frequency  and 
duration." 

This  experienced  surgeon  also  gives  some  additional  valuable 
advice  :  "  The  practicing  of  these  pressures  must  not  be  indifferently 
consigned  to  any  one.  A  mother's  affection,  alone,  is  capable  of  the 
perseverance  requisite  for  success ;  with  this  ally,  there  is  scarcely 
any  malformation  of  the  kind  we  have  described  that  cannot  be 
remedied;  and  I  have  seen  children  who  were  dreadfully  afflicted^ 
become  eventually  strong  and  well  constituted."  Indifference  to 
the  advice  of  the  surgeon  is  the  most  common  cause  of  failure  to 
cure  chronic  ailments  of  whatever  character;  but  more  especially 
deformity  of  limbs  or  body. 

The  constant  vigilance  and  actual  labor  required  in  treatment,  as 
advised  by  Dupuytren,  would  not  be  readily  obtained  from  even  the 
majority  of  mothers.  The  great  difficulty,  and  almost  impossibility 
of  obtaining  this  extraordinary  attention  upon  a  patient  to  effect  a 
cure  induces  a  more  favorable  consideration  of  treatment  that  can 
be  made  readily  available,  and  to  the  cure  of  the  patient,  with  as 
much  certainty  as  the  above  almost  impossible  requirement,  which 
if  not  judiciously  practiced  must  tend  to  the  compromising  of  the 
patient's  life  from  undue  pressure  upon  the  chest. 


GENU   EXTROESUM. 

Bow-legs  are  among   the  curable    contortions   occurring  among 
children  whose  constitutions  are  defective  —  mainly  rachitic,  but 


Ra  chitis. 


205 


mg.  84. 


invariably  fleshy  and  clumsy  in  appearance;  the  body  rocking  from 
side  to  side  each  step  that  is  taken,  and  the  curved  leg  yielding  likp 
a  spring,  the  vertical  bearing  defective.  Hence,  it  is  commonly 
said,  that  the  child's  legs  were  straight  when  born,  but  became 
mirved  from  its  weight  when  it  commenced  to  walk  —  which  was  at 
an  advanced,  age  —  the  child,  also,  having  been  late  in  teething. 
See  Fig.  84 

Eepresents  the  deformed  legs.  The 
tibia  and  fibnla  of  the  legs  aro  curved 
in  a  lateral  direction  —  in  some  cases  to 
an  extraordinary  degree,  commencing 
from  the  external  malleolus,  which  in 
some  children  nearly  touches  the  floor. 
The  legs  diverge  from  each  other  in  one 
continuous  curved  line  from  the  hips  to 
the  ankles.  The  femur,  however,  is  but 
seldom  implicated  in  the  curve,  other 
than  adaptation  to  the  lower  curve. 
True  diagnosis  of  the  condition  of  the 
limbs  is  of  much  importance  in  the  treatment  of  bow-legs  in 
children. 

In  many  cases  they  can  be  cured  without  instrumental  aid;  the 
lateral  divergence  of  the  legs  resulting  from  a  relaxed  condition  of 
the  ligaments  about  the  joints  (the  bones  having  maintained  their 
integrity),  and,  as  the  child  increases  in  strength  from  a  prescribed 
regime,  ox,  improves  in  strength  without  interference,  the  deformity 
disappears. 

It  is  this  favorable  tendency  that  disparages  treatment  in  the  early 
stage  of  the  ailment,  often  to  the  patient's  great  disadvantage.  If, 
after  having  arrived  at  the  age  of  six  or  eight  years,  effort  is  then 
made  for  their  improvement,  the  patients  will  not  only  suffer  severely, 
but  their  health  will  be  endangered  thereby,  because  of  the  force 
required  to  overcome  the  curved  and  hardened  bones. 

If,  on  examination,  the  tibias  are  found  to  curve  laterally,  and  the 
knee-joints  to  maintain  their  integrity  of  adaptation,  and,  when 
■efforts,  in  some  form,  are  made  to  straighten  the  leg,  the  limbs 
maintain  a  persistent  resistance  to  the  force;  the  earlier  instru- 
mental force  is  applied  the  less  inconvenience  and  pain  will  ensue  to 
the  patient,  and  this  treatment  they  must  have,  or  remain  bow- 
ileggL'd  through  life. 


206  Or  thop^dia  . 

It  occasionally  occurs  that  one  limb  will  curve  laterally,  and  the 
other  posteriorly;  presenting  the  appearance  of  one  leg  being  straight 
and  the  other  curved,  when  the  patient  is  standing  in  front  of  the 
observer.  The  parents,  of  the  child  so  impressed,  are,  in  such 
cases,  very  apt  to  insist  that  only  one  leg  requires  treatment  and 
this  arises  from  the  fact  that  a  very  decided  curve  j)osteriorly,  in 
the  leg  below  the  knee,  is  not  nearly  so  apparent  as  the  lateral  de- 
viation. Both  are  equally  amenable  to  relief  when  suitable  appli- 
ances are  devised  to  meet  each  indication. 

TEEATilEXT  OF    GEXU   EXTOKSIUM. 

The  child  laboring  under  relaxed  ligaments  of  the  joints  will 
be,  most  commonly,  found  to  have  a  tumid  abdomen  and  an  enlarge- 
ment of  the  ankle,  knee  and  wrist  joints, —  indicating  the  rachitic 
diathesis  of  the  patient,  and  requiring  constitutional  treatment 
for  this  ailment,  which  may  be  left  to  the  family  practitioner.. 
By  this  means  a  cure  in  some  instances  can  be  effected  in  the  course 
of  time,  but  in  much  less  time  by  the  auxiliary  aid  of  suitably 
devised  light  steel  supports,  although  these  are  much  objected  to  by" 
eminent  authority, —  which  objection  we  believe  to  be  founded  upon 
an  erroneous  impression,  gained  from  the  observation  of  defective- 
apparatus  devised  by  the  instrument  makers  and  not  thac  of  the- 
skilful  surgeon.  Support  tending  to  establish  a  vertical  bearing 
upon  the  limbs  would  surely  tend  to  relieve  the  relaxed  ligaments- 
and  establish  an  equilibrium  of  muscular  tension  that  cannot  be- 
otherwise  than  a  therapeutic  aid  of  considerable  merit. 

In  cases  of  lateral  deviation  of  the  shafts  of  the  tibia  and  fibula,, 
while  the  knee  joints  maintain  their  integrity,  there  is  muscular 
retraction  on  the  inner  side  of  the  legs,  to  which  force  the  bones 
have  yielded  ;  whether  abnormally  soft  or  not,  we  believe  them  to 
be  in  a  pathological  condition,  and  the  indications  can  only  be  met. 
by  mechanical  support  and  that  most  readily;  as  the  long  bones  of 
children  are  very  flexible  and  can  be  easily  overcome  by  moderate,. 
continued  force  to  the  improvement  of  form.  That  there  exists  a. 
faulty  functional  condition  of  the  child  thus  afflicted  is  quite  appar- 
ent from  its  condition.  Xervous  irritability  limited  to  certain 
muscles  would  tend  to  induce  this  condition  of  the  legs,  without- 
impairing  the  function  of  nutrition ;  as  children  thus  conditioned 
are  usually,  as  before  stated,  very  fleshy,  and  this  irritability  having 
subsided,  mechanical  treatment,  alone,  is  indicated. 


Rachitis. 


207 


Fig.  85.  Eepresents    our    apparatus    applied.     It  consists  of  a 
straight  bar  of  steel  extending  from  the  internal  malleolns  to  the 
inner  condyle  of  the  os  femur,  cushioned  at  either  end,  and  secured 
Fig.  85.  by  semi-circular  steel  bands  and  straps 

to  an  outer  bar,  limited  in  length  —  as 
seen  in  the  apparatus  not  applied — be- 
tween which  a  broad  belt  of  strong 
woven  fabric  is  made  to  encircle  and  lace 
in  front,  passing  over  the  inner  bar  and 
inside  of  the  outer  one.  This  has  a  direct 
broad  bearing  against  the  outer  surface 
of  the  leg,  and,  when  laced,  tends,  from 
the  counter  resistance  of  the  inner  bar, 
to  straighten  the  leg.  The  outer  bar 
and  encircling  bands  sustain  the  appli- 
ance in  situ.  The  apparatus  shown  as 
not  applied  represents  the  form  of  that 
applied  to  the  leg  in  Avhich  the  outer  bar 
is  not  seen  because  of  the  position  of 
the  leg.  As  before  stated,  the  broad  belt  is  passed  free  within  the 
outer  bar  and,  as  seen,  over  the  inner.  It  will  be  observed  that  there 
is  an  instep  pad  and  tapes  that  secure  the  foot  to  the  sole-plate  and 
heel-cup.  The  latter  should  be  made  the  size  of  the  foot,  so  as  to 
be  worn  at  night  —  an  essential  necessary  to  the  obtaining  of  a 
speedy  cure. 

Fig.  86.  Rep- 
resents a  child 
clothed  and  hav- 
ing the  braces  on. 

Fig.  87.  Eep- 
resents the  form 
of  the  brace  when 
applied  for  the 
cure  of  the  pos- 
terior curve  of 
the      tibia     and 

fibula.  1,  a  steel  band  to  be  applied 
over  the  head  of  the  tibia.  2,  the  in- 
step pad  that  secures  the  foot  in  the. 
heel  cup.      These  two  points  of  sup- 


Fig.  87. 


Fig.  86. 


208 


Urthop^bia. 


port  maintain  the  fixed  position  of  the  \Qg  for  counter-pressure 
which  is  made  by  the  hxcings  (3)  over  the  gastrocnemius  muscles 
tending  to  straighten  the  leg.  With  this  form  of  apparatus  we 
straighten  the  irregular  posterior  bending  of  tlie  bones  of  the  leg. 
The  legs  should  be  examined  twice  a  day,  and  tender  points  pro- 
tected with  ravelings  from  worn  .linen  fabric.  This  is  much  superior 
to  lint,  which  will  become  impacted  and  hard  when  firmly  com- 
pressed. Bathing  the  limbs  frequently,  and  manipulating  them 
with  as  much  pressure  as  the  patient  will  bear  is  of  decided  advant- 
age, besides  afi'ording  actual  comfort  because  of  the  support  given 
to  the  yielding  leg  when  walking. 


GENU  VALGUM. 

In  this  difficulty,  as  in  many  others,  we  have  indications  of  an 
enfeebled  constitution.  Knock-knee,  the  reverse  of  bow-legs,  is  a 
subject  of  study,  for  the  condition  that  has  tended  to  one  or  the 
other  is  very  obscure  and  not  definable  with  a  comprehensiveness 
that  would  decide  the  pathological  condition  of  either.  In  the  bow- 
leg aberration  there  is  an  apparent  deficiency  in  osseous  pabulum, 
and,  from  the  attenuated  condition  of  the  patient  having  knock- 
knees,  a  deficiency  in  muscular  nutrition. 

In  the  incipient  stage  of  this  ailment  in  children,  there  will  be 
found  great  mobility  of  the  joints ;  and,  if  the  knees  are  slightly 
inclined  inward  wlien  the  child  is  standing  they  will  become 
apparently  straight  when  lifted  off  the  floor,  or,  after  the  inclination 
has  assumed  a  decided  form,  the  legs  can  be  extended  quite  straight 
with  the  hands  without  giving  pain  to  the  child. 

Fig.  88.     Eepresents  a  case  of  knock- 
knee  in  a  child. 

Children  having  knock-knees  are, 
usually,  greatly  attenuated  in  muscular 
development,  presenting  a  most  delicate 
appearance  compared  with  that  of  chil- 
dren having  bow-legs.  Their  general 
health  is  greatly  impaired  ;  the  secretions 
unhealthy;  the  appetite,  in  some  cases, 
voracious,  and  in  all  precarious ;  the 
surface  dry  and  contracted ;  the  abdomen  '-g=^,  / 
large,  and  the  anterior  spinous  processes 
protuberant.      This  ailment  is  not  limited 


Fig.  88. 


Ra  chitts. 


209 


to  infants,  but  children  of  ten,  twelve,  and  fourteen  years  of  age 
are  alike  subject  to  the  deformity.  In  some  cases  the  patient  will 
have  knock-knee  of  one  leg  and  a  posterior  inclination  of  the  other ; 
and,  if  not  relieved  by  mechanical  support,  finally  become  unable  to 
walk  from  its  increasing  tendency. 

Mr.  Tamplin  states  in  his  lectures  that  this  is  not  a  congenital 
■deformity,' — at  least,  he  had  never  seen  a  congenital  case  nor  could, 
he  imagine  how  it  could  occur  provided  we  admit  that  congenital 
■distortion  arises  from  malposition  in  utero.  We  have  treated  two 
■cases  of  congenital  knock-knee,  and,  what  was  peculiar  in  both, 
the  feet  were  turned  inward  and  upward ;  being  cases  of  exaggerated 
talipes  varus  conjoined  with  genu  valgum.  In  ordinary  cases,  more 
especially  of  young  children,  valgus  is  the  most  common  concomi- 
tant. 

TEEATMEXT   OF   GENU   VALGUM. 

In  the  treatment  of  children  we  have  never  availed  ourselves  of 
myotomy,  or  found  any  necessity  for  it ;  the  cases  being,  usually, 
readily  redressed  by  mechanical  supports.  In  cases  of  advanced 
age,  the  severing  of  the  biceps  flexor  femoris  is  necessary.  In  this 
operation,  care  must  be  taken  to  avoid  dividing  the  peroneal  nerve 
—  an  unfortunate  occurrence  that  has  been  the  lot  of  several  ortho- 
paedists. Paralysis  of  the  flexors  of  the  foot  is  the  result  of  such 
an  accident,  and  great  alarm  is  given  to  patients  and  friends,  though 
it  is  said  that,  in  time,  the  use  of  the  paralyzed  muscle  is  recovered. 
To  avoid  the  accident,  press  the  knife  close  under  the  tendon,  and 
p^^  gg  not  beyond  it,  and  make  no  attempt  to 

divide  the  other  tense  fascicula  which  will 
be  observed  after  the  tendon  is  divided. 
Immediately  after  dividing  the  tendon  we 
apply  the  steel  spring  appliance  for  re- 
dressing the  deformity;  constitutional 
treatment  being  implied,  as  in  all  cases 
u,  \\  j(  }\.  Jl  of  like  condition. 
/^      N      T?     Tl     li  Figure  89  represents  the  construction 

V  I  ki^  I       UJ  1  Qf  ^}-,g  apparatus,  having  steel  soles,  and 

cups  in  which  the  heel  is  to  be  secured; 
1,  a  steel  belt  to  encircle  the  body ;  2, 
a  joint  that  can  be  controlled  by  a  slide 
—  useful  in  severe  cases. 

Fig.  90  represents   the   apparatus  ap- 


210 


Orthopmbia. 


plied.  Here  the  strong,  outer  bar  is  shown,  to  which  the  leg 
is  tending  by  means  of  the  encircling  bands ;  the  inner  bars 
cushioned  at  the  joints  bearing  against  the  inner  condyle  of 
the  femur.  Gaiters  should  be  worn  over  the  foot  support,  to 
keep  it  clean  and  render  it  nnobjectionable  to  be  worn  in  bed 
—  in  fact,  not  only  gaiters,  but  other  clothing,  as  seen  in  that 
used  in  the  treatment  of  bow-legs,  for  the  braces  must  be 
worn  constantly,  day  and  night,  and  no  attempt  made  to  stand 
upon   the  feet    without  them.    The  pa-  Fig.  90. 

tient  may  have  them  taken  off"  several 
times  during  the  day,  and  have  the 
limbs  manipulated  and  bathed,  but 
must  always  at  such  times  be  in  a  recum- 
bent position. 

Efforts  at  walking  are  of  great  advan- 
tage in  the  treatment,  although  distress- 
ing at  first,  as  the  knees  will  be  thrown 
forward  to  a  half  kneeling  position,  in  se- 
vere cases,  but  this  very  uncomfortable 
and  unavailable  effort  to  straighten  the 
limbs  contributes  largely  to  their  resto- 
ration of  normal  form,  as  the  patient  en- 
deavors to  extend  the  contracted  muscles. 
The  slide  rendering  the  joint  immovable 
can  only  be  made  available  during  the  night,  when  it  retains  the  legs 
in  a  straightened  position,  tending  largely  to  the  restoration  of  tone 
to  the  Aveakened  muscles  and  ligaments,  the  result  of  the  continued 
extension.  When  the  normal  form  is  attained,  and  the  necessity 
for  extension  appliances  no  longer  exists,  and  the  general  health  of 
the  patient  is  improved,  strength  is  readily  restored. 

In  cases  of  advanced  age  the  treatment  described  cannot 
be  of  reliable  service.  Fracturing  of  the  bones  has  been  success- 
fully practiced  without  injury  to  the  patient. 

Dr.  William  T.  Bull,  one  of  our  Consulting  Surgeons,  and  Visiting 
Surgeon  to  St.  Luke's  and  the  New  York  City  Hospitals,  has  been 
very  successful  in  restoring  to  normal  form  many  extraordinary 
cases  of  this  sad  deformity  when  in  advanced  age — as  that  of  seven- 
teen years  old — and  no  unfavorable  sequelae  followed  the  treat- 
ment. 


CHAPTER   IX. 

HERMIA  — PROCIDENTIA  UTERI  — ECTROPION  VESICA  — 
RELAXED  ABDOMEN. 

Derivation  of  tlie  term. —  Formerly  defined  as  "  protrusion  of  any  of  the 
abdominal  viscera." — Danglison's  definition. —  Treatment. —  Abdominal  Hernia, 
its  Varieties. —  Scarpa's  Exposition. —  More  recent  authorities  on  Hernia. — 
Causes  of  Hernia. —  Varicose  Veins  and  Aneurism. —  Symptoms  of  Abdomina^. 
Hernia. — Various  Denominations  of  Hernia. —  Divisions  of  the  various  Abdom- 
inal Hernia. —  Strangulated  Hernia. —  Diagnosis. —  Glandular  Tumors. —  Symp- 
toms, as  distinguished  from  apparently  similar  affections. —  Hydrocele. —  Con- 
genital Hernia. —  Circocele. —  Sir  Astley  Cooper's  mode  of  treatment. —  Femoral 
Hernia. —  Glandular  enlargements  and  Psoas  abscess  sometimes  mistaken  for 
Hernia. —  Hernia  complicated  with  a  retained  testicle. —  Essentials  to  a  correct 
diagnosis  of  hernial  protrusion. —  Prognosis. — Liability  to  stricture. —  Possi- 
bility of  gradual  reduction. —  Taxis,  or  reduction  by  the  hand. —  Should  not  be 
attempted  in  the  case  of  an  enlargement  of  the  omentum  or  intestine. —  Symp- 
toms of  Hernia. —  Incarcerated  Hernia. —  Treatment. —  Advantage  of  applica- 
tion of  Taxis  in  femoral  Hernia. —  Sir  Astley  Cooper's  advice  as  to  treatment 
in  strangulated  Hernia. —  Statement  of  Dr.  Philip  Crampton  Smyly,  of  Eng- 
land, on  treatment  of  hernia. —  Testimony  of  Dr.  Thomas  Bryant,  surgeon  to 
Guy's  hospital. —  His  novel  means  of  reducing  Strangulated  Hernia. —  The 
construction  and  application  of  trusses  for  the  relief  of  Abdominal  Hernia. — 
There  is  no  one  form  of  truss  or  uniformity  of  pad  adaptable  to  all  the  varie- 
ties of  hernia. —  Patients  suffering  from  hernia  in  an  exceptionally  perilous 
condition. —  Palliative  and  preventive  treatment,  v^hile  in  a  reducible  condi- 
tion, the  only  proper  course. —  Usual  origin  of  Hernia. —  Predisposition  to 
Hernia  evinced  by  relaxed  condition  of  abdominal  muscles. —  Forms  of  truss, 
single,  double  and  children's. —  Rationale  of  cure  of  hernia  in  adults. — 
The  author's  truss  for  the  relief  of  reducible  Inguinal  and  Femoral  Hernia. — 
Procidentia  Uteri. — Pathological  condition  similar  to  hernia. — Primary  cause. 

—  Symptoms. —  Derangement  of  system  consequent  upon  the  ailment. — 
Escharotic  applications  only  palliative  and  often  injurious. —  Treatment  of 
Procidentia  Uteri. —  Anteversion  of  the  Uterus. —  Prolapsus  Vesicae. —  Neces- 
sary appliances. —  Ectropion  Vesicae,  or  Extroversion  of  the  Bladder. —  Diag- 
nosis.—  Mode  of  relief. —  Relaxed  abdomen. —  Prolapsus  Ani  and  Hemorrhoids, 

—  Causes. —  Diagnosis. —  Treatment. 


212  Orthopmbia. 

HERNIA. 

In  this  chapter  upon  Hernia,  Ave  shall  not  confine  the  limits  of  this 
ailment,  as  former  writers  have  done,  to  the  three  general  divisions, 
the  head,  chest  and  abdomen ;  as  analogous  conditions  exist,  and 
are  quite  as  common  in  the  limbs  as  in  the  parts  formerly  desig- 
nated. Heuce,  in  addition  to  these  boundaries,  we  include  the 
limbs;  they  being  subject  to  similar  pathological  conditions  —  as 
in  that  of  varix  and  aneurism. 

This  seeming  nmovation  upon  the  established  limits  of  hernia  is 
assumed,  because  of  the  derivation  of  the  term  liernia,  a  branch,  that 
is,  a  limb  or  portion  to  protrude  from  ;  including  in  a  pathological 
sense  of  the  term,  all  protrusions  similar  to  those  usually  considered 
as  confined  to  the  limited  boundaries  of  the  head,  chest  and 
abdomen.  Hernia  was  formerly  defined  as  protrusion  of  "  any  of 
the  abdominal  viscera  from  the  cavity  in  which  they  are  naturally 
contained  into  a  preternatural  bag,  formed  by  the  protrusion  of  the 
peritoneum,  constituting  a  hernia  or  rupture,  according  to  the  most 
common  acceptation  of  the  term."  *  This  definition  of  hernials 
less  tenable  than  that  of  the  limited  boundaries  before  stated ;  as 
in  protrusion  of  the  bladder,  hernia  vesica,  there  is  no  hernial  sac, 
nor  is  there  in  congenital  hernia  within  the  tunica  vaginalis.  In 
Duhglison's  Medical  Dictionary  we  find  designated  :  Hernia  arte- 
rium,  hernia  venarium,  varicose  vein;  hence,  we  include  these 
pathological  conditions  of  the  limbs  under  the  designation  of 
hernias,  requiring  somewhat  similar  therapeutic  agents  for  treat- 
ment ;  considering  the  term  hernia  to  include  all  protrusions  from 
within  the  body  and  limbs  and  sustained  by  superficial  integument, 
being  the  result  of  a  yielding  of  the  supporting  tissues  and,  when 
reducible,  amenable  to  relief  from  the  application  of  surgico- 
mechanical  appliances. 

Hernias,  in  regard  to  treatment,  agree  with  other  deformities ; 
they  being  also  aberrations  of  the  body  and  limbs  requiring  for 
treatment  a  similar  class  of  agents. 

ABDOMINAL   HERNIA  —  ITS   VARIETIES. 

Scarpa  remarks  in  his  Traite  des  Hernies :  ''  No  anatomist 
would  believe  that  the  intestine  coecum,  naturally  fixed  in  the  right 
ilium,  and  the  urinary  bladder,  situated  at  the  bottom  of  the  pelvis, 

*  Lawrence's  Treatise  on  Ruptures,  and  additions  by  J.  Parrisli,  M.  D.,  p.  3. 


Hernta  —  Procidentia   Uteri,  etc.  213 

could  undergo,  without  being  torn,  so  considerable  a  displacement 
as  to  protrude  through  the  abdominal  ring,  and  descend  even  into 
the  scrotum;  that  the  same  intestine,  the  coecam,  could  pass  from 
the  right  iliac  region  to  the  umbilicus,  so  as  to  protrude  at  this 
opening  and  form  an  umbilical  hernia  ;  that  the  right  colon  could 
have  been  seen  protruding  from  the  abdomen  at  the  left  abdominal 
ring,  and  the  left  colon  through  the  right  one;  that  the  liver,  the 
spleen  and  ovary  could  sometimes  be  the  parts  contained  in  the 
umbilical,  inguinal,  and  femoral  hernia ;  that  the  coecum  could  engage 
itself  within  the  colon,  and  even  protrude  at  the  anus ;  that  the 
stomach  forced  through  the  diaphragm  could  form  a  hernia  within 
the  chest;  that  the  omentum,  or  intestine,  or  both  these  parts 
together,  could  sometimes  make  their  escape  from  the  belly  through 
the  foramen  ovale  or  sacro-ischiatic  notch  of  the  pelvis ;  that  a 
noose  of  small  intestines  after  being  engaged  in  the  abdominal  ring, 
or  under  the  femoral  arch,  could  suflFer  the  most  violent  strangula- 
tion without  the  course  of  the  intestinal  matter  being  intercepted ; 
lastly,  that  in  certain  circumstances  the  intestine  and  omentum 
could  be  in  immediate  contact  with  the  testicle,  within  the  tunica 
vaginalis  without  the  least  laceration  of  this  latter  membrane." 

This  very  celebrated  anatomist  carefully  obtained  these  facts,  that 
have  been  since  proved  by  numerous  obs'Tvations  on  individuals 
affected  with  hernia,  and  very  elaborate  accounts  given  of  them  by 
such  eminent  authority  as  that  of  Sir  Astley  Cooper  and  Mr.  Wil- 
liam Lawrence,  who  have  given  us  the  most  reliable,  modern  works 
upon  the  subject  of  hernia,  up  to  1861,  Avhen  the  Jacksonian  prize 
of  the  Royal  College  of  Surgeons,  London,  was  given  to  John  Wood,*' 
F.E.O.S.,  for  an  essay  on  "Eupture,  Inguinal,  Crural  and  Um- 
bilical." 

CAUSES. 

The  causes  of  hernia  have  been  resolved  into  two  conditions ; 
those  that  impair  the  resistance  of  the  abdominal  muscles  —  a 
relaxed  and  debilitated  condition  of  tissues,  as  in  varicose  veins  and 
aneurism,  and  those  that  increase  the  pressure  of  the  viscera;  such 
as  violent  exertion  or  accident. 

The  first  condition  may  be  considered  as  predisposing  to  hernia,, 
and  is  admitted  by  the  most  reliable  authority  to  be  an  elongation 
of  the  attachments  of  the  viscera,  tending  to  an  undue  descent 
upon  the  equally  unfavorably  conditioned  boundaries  of  the  abdo- 
men.    Whatever  influence  may  tend  to  impair  the  tenacity  of  the 


214  Orthop^dia. 

system;  as  that  of  sickness,  arduous  and  continuous  labor,  poor 
diet,  aud  long  continued  mental  depression,  may  be  considered  as  a 
first  cause,  and  these  unfavorable  influences,  to  a  limited  extent, 
reach  all  classes  of  people,  hence  the  exceeding  preTalence  of  this 
almost  incurable  ailment,  abdominal  hernia,  only  amenable  to  pal- 
liative treatment.  Hernias  are  the  most  common  of  physical  ills 
to  which  the  human  family  is  liable,  and  the  above  stated  condi- 
tions of  the  system  tend  most  to  their  production.  The  ailment  is 
apparently  hereditary  in  many  families,  their  constitutionally  lax 
fibre  predisposing  them  to  these  protrusions  in  various  parts  of  the 
body  and  limbs.  It  is  a  most  common  circumstance  to  find  a  person 
laboring  under  hernia,  to  be  also  subject  to  hemorrhoids  and  varicose 
veins. 

Causes  tending  to  produce  an  increased  pressure  upon  the  viscera 
are  various  but  comprehensible.  In  the  powerful  action  of  the  ab- 
dominal muscles  and  diaphragm  on  the  viscera  in  feats  of  agility, 
such  as  tossing  an  immense  weight,  and  jumping,  the  pressure  upon 
the  contents  of  the  abdomen  is  sufficient  to  produce  a  hernia  in  the 
most  robust  persons,  as  we  have  witnessed  in  many  instances,  and 
violence  to  the  person,  as  in  case  of  concentrated  force  from  a  fall 
upon  some  projecting  point  of  hard  substance  or  pointed  instrument 
thrust  against  the  abdominal  walls  —  more  especially  after  a  full 
meal  —  and  yet  not  penetrating  the  skin,  but  separating  the  mus- 
cular fibre.  If  not  apparent  immediately,  a  hernia  presents  in  time, 
and  denominated  ventral,  or  adventitious,  from  its  not  protruding 
from  the  ordinary  localities  of  hernial  protrusions. 

SYMPTOMS. 

The  ordinary  symptoms  of  abdominal  hernia  are,  an  indolent 
tumor  at  some  point  of  the  parietes  of  the  abdomen  —  most  fre- 
quently protruding  out  of  the  abdominal  ring,  or,  from  below  Pou- 
part's  ligament,  or  of  the  navel  cincture,  and,  occasionally,  from  va- 
rious other  situations;  the  swelling  of  the  integuments,  suddenly, 
and  subject  to  a  change  of  size — being  smaller  in  some  cases,  and 
entirely  disappearing  at  times,  as  when  the  patient  assumes  a  recum- 
bent position  during  the  night,  and  increasing  when  standing  up 
or  holding  the  breath,  which  is  the  most  positive  indication  of  the 
existence  of  a  hernia.  The  viscera,  if  reducible,  will  diminish  when 
pressed,  and  after  a  time  reappear.  Fluids  follow  on  the  remo- 
val of    pressure  —  tumors   from   indurated   tissues   are   not   com- 


Hernia  —  Procidentia   Uteri,  etc.  215 

monly  attended  with  nausea  and  sickness,  are  not  reducible.  The 
size  and  tension  often  increase  after  a  meal  or  when  the  patient 
is  flatukint.  Patients  afflicted  with  hernia  are  subject  to  colic,  con- 
stipation, and,  often  vomiting,  in  consequence  of  the  displacement 
of  the  bowels  —  or,  if  replaced  after  having  been  protruded  in  large 
quantity  for  some  considerable  duration  of  time.  The  protrusion, 
in  many  cases,  produces  but  comparatively  little  inconvenience  to 
the  person,  other  than  exposure  to  sight  when  very  large. 

In  ordinary  cases,  a  patient  affected  with  even  a  small  hernia  will, 
when  laughing  or  sneezing,  find  the  tumor  instantaneously  increase 
in  size,  if  not  supported,  or,  involuntarily,  as  it  were,  pressed  upon 
by  the  hand.  Its  tendency  to  increase  in  size,  in  many  instances, 
very  rapidly,  renders  it  quite  apparent  that  the  mesenteric  attach- 
ments are  elongated  and  in  direct  ratio  to  the  quantity  of  the  viscus 
protruded,  dragging,  as  it  were,  the  most  distant  viscera  (in  the 
normal  state  firmly  fixed  by  the  folds  of  the  mesentery)  to  the  de- 
scending hernia  and  becoming  a  part  of  the  protrusion. 

The  contents  of  an  ordinary  hernia,  in  most  cases,  present  dis- 
tinguishing indications  by  which  the  viscus  filling  the  sac  may  be 
determined.  If,  by  intestine,  the  protrusion  is  denominated  eiitro- 
cele,  and  if  by  a  portion  of  the  small  intestines,  the  tumor  is  usually 
small  and  liable  to  become  painful  and  tense  from  any  distending 
cause,  and  will  resist  efforts  at  reduction.  However,  it  is,  in  most 
cases,  very  readily  redressed  even  when  large  portions  protrude. 
Upon  coughing,  the  intestine  will  feel  as  if  blown  into,  and  when 
pressed  into  the  abdomen  will  be  attended  with  a  gurgling  sound. 

If  the  hernia  consists  of  omentum  it  is  denominated  epiplocele, 
and  the  contents  distinguished  by  the  sensation  of  pressing  a  mass 
of  dough,  having  greater  weight  when  largely  protruded,  and  when 
being  reduced  passes  in  without  sound. 

DIVISIONS    OF   THE   VARIOUS   ABDOMIiSTAL   HERISTIA. 

Hernia  has  also  its  local  designation ;  as  when  the  viscera  pass 
directly  from  the  abdominal  cavity,  taking  the  course  of  the  sper- 
matic cord,  or  round  ligament,  it  is  denominated  Oblique  Inguinal 
Hernia  ;  and  when  it  passes  directly  through  the  internal  abdominal 
ring,  so  that  its  direction  from  the  external  protrusion  is  direct,  and 
not  oblique,  it  is  known  as  direct  inguinal  hernia.  When  situated 
over  the  internal  ring  in  the  form  of  a  small  tumor,  it  is  named 
bubonocele,  and  congenital  when  the  protruding  viscus  is  found  within 


216  Orthop^dia. 

the  tunica  vaginalis ;  ventral,  when  protruding  at  irregular  parts  of 
the  abdomen  —  usually  the  result  of  violent  penetration  of  the  mus- 
cle and  not  the  skin ;  exomphalos  or  umbilical  hernia  when  pro- 
truding at  the  navel.  These  are  the  most  common  varieties  of 
hernia,  though  there  are  others  —  as  vaginal  and  perineal  hernia, 
and  all,  if  reducible,  are  amenable  to  relief  —  and,  in  infants,  nearly 
all  curable  by  means  of  well  devised  surgico-mechanical  appliances. 

It  is  essential  to  have  a  pi-actical  knowledge  of  the  various  condi- 
tions of  hernia,  as  they  present  in  different  persons,  and  under  .every 
peculiar  circumstance,  to  give  even  a  promise  of  anything  approach- 
ing to  successful  treatment,  as  it  is  one  of  the  most  intricate  patho- 
logical conditions  to  which  man  is  subject.  And  yet,  patients  thus 
afflicted  are  often,  without  proper  consideration,  submitted  by  the 
medical  practitioner  to  the  uneducated  in  medical  science  for  treat- 
ment. We  allude  to  venders  of  trusses  —  mere  adventurers,  having 
some  patent  truss  intended  principally  for  sale.  This  is  much  to 
be  regretted,. as  it  is  estimated  that  every  tenth  person  is  so  afflicted, 
and  every  one  thus  conditioned,  liable  to  a  violent  death  if  not 
skilfully  treated  by  the  application  of  a  suitable  truss  meeting  the 
indications  that  may  present. 

The  eminent  S.carpa  says,  in  his  treatise  on  Hernia:  "There  are 
indeed  a  certain  number  of  surgical  operations  for  the  prompt  and 
safe  execution  of  which  mere  anatomical  knowledge  will  suffice ;  but 
in  many  others  the  surgeon  cannot  promise  himself  success,  even 
though  he  be  well  acquainted  with  anatomy,  unless  he  has  particu- 
larly studied  the  numerous  changes  of  position  and  alterations  of 
texture  of  which  the  parts  upon  which  he  is  about  to  operate  are 
susceptible.  If  he  has  not  the  requisite  information  upon  all  these 
points,  false  appearances  may  deceive  his  judgment  and  make  him 
commit  mistakes,  sometimes  of  a  very  serious  and  irreparable  kind. 
In  order  to  have  a  convincing  proof  of  this  truth,  it  will  be  suffi- 
cient to  take  a  view  of  the  different  species  of  hernia  and  their 
numerous  complications." 

These  remarks,  it  is  true,  are  made  upon  the  surgical  operation 
for  the  relief  of  strangulated  hernia ;  but,  nevertheless,  are  appli- 
cable to  the  treatment  of  reducible  hernia;  because  of  the  different 
species  and  complications,  and  the  necessity  for  security  against  the 
liability  to  the  unskilful  use  of  the  knife.  And  it  matters  not  how 
skilfully  the  operation  is  performed,  it  is  attended  with  doubtful 
premonition  as  to  the  saving  of  the  patient's  life:  there  is  greater 


Hernia  —  Procidentia   Uteri,  etc.  217 

safety  in  a  truss  properly  applied,  and  varied  in  form  so  as  to  oap- 
fcate  to  the  hernial  parietes,  and  retain  the  viscera  in  sihi — thus 
protecting  the  patient  from  the  serious  condition  here  alluded  to. 

DIAGNOSIS. 

When  an  inguinal  hernia  is  first  formed,  the  two  rings  maintain 
their  relative  position.  The  internal  ring  is  to  be  found  at  equal 
distance  of  the  space,  between  the  anterior  superior  spinus  process 
of  the  ilium,  and  the  angle  of  the  pubis.  From  this  point  the 
inguinal  canal  descends  obliquely  downwards,  between  the  aponeu- 
rosis of  the  external  oblique  and  the  fascia  transversalis. 

The  viscera  having  entered  the  internal  ring,  may  be  detected  in 
the  canal,  where  it  remains  during  the  erect  position  of  the  patient 
—  presenting  a  somewhat  oblong  tumor  that  disappears  when  the 
patient  is  in  a  recumbent  position  for  several  hours,  or,  can  be 
reduced,  when  not  painful,  by  taxis.  This  stage  of  hernia  is  liable 
to  give  much  inconvenience  to  the  patient  —  a  dull  pain  in  and 
about  the  epigastric  region,  tending  even  to  nausea  and  a  general 
distressed  feeling.  In  many  instances,  because  of  its  obscurity,"  the 
ailment  remains  unobserved  by  the  patient.  This  condition  of 
hernia  is  the  same  in  the  female  as  in  the  male,  and  the  round  liga- 
ment has  the  same  relation  to  the  swelling  as  the  spermatic  cord  in 
the  male.  The  viscera,  if  not  reduced  and  retained  by  a  truss,  will 
eventually  descend  and  pass  through  the  external  ring,  when  it  will 
be  observed  as  a  circular  tumor;  or,  the  viscera  may  protrude 
directly  through  the  external  ring  from  within  the  abdomen,  and 
present  a  similar  appearance  —  the  condition  only  being  known 
when  the  hernia  is  reduced,  the  opening  passing  directly  into  the 
abdomen,  and  not  obliquely  as  when  through  the  inguinal  canal. 

Glandular  tumors  are  not  reducible,  and  are  not  found  in  the 
location  of  the  internal  or  external  rings,  or  in  the  direction  of  the 
the  canal,  hence,  not  readily  confounded  with  hernia  if  the  anatomy 
of  the  inguinal  region  is  carefully  considered. 

When  the  viscera  has  descended  into  the  scrotum  it  must  be  dis- 
tinguished from  other  complaints.  If  a  swelling  of  the  scrotum  is 
uniform  on  its  surface  and  commenced  in  the  most  pendent  portion, 
gradually  ascending,  and  we  cannot  feel  the  testicle,  but  are  able  to 
discern  the  spermatic  cord  of  its  natural  size,  and  in  a  healthy  state 
above  the  tumor,  and,  particularly  if  we  can  distinguish  a  fluctua- 
tion, or  discover  a  degree  of  transparency  in  it  by  holding  a  lighted 


218  Orth  op^dta  . 

candle  in  front  of  it,  we  are  then  assured  of  an  effusion  of  fluid  into 
the  cavity  of  the  tunica  vaginalis  testis,  A  protrusion  of  the  vis- 
cera is  first  observed  emanating  from  the  abdominal  rings  and  gradu- 
ally descending,  when  the  spermatic  cord  cannot  be  felt  but  the 
testicle  may  be  distinguished,  and  when  the  symptoms  described 
above  as  belonging  to  a  hydrocele,  and  the  indication  of  hernia 
also.  They  may  both  exist  at  one  time.  This  condition  is  found 
in  infants,  and  serves  to  perplex  ths  professional  attendant  if  not 
aware  of  the  possibility  of  the  co-existence  of  the  two  ailments. 

The  origin  of  enlargements  within  the  scrotum,  if  below  or  above, 
is  alone  to  be  relied  upon  for  a  diagnosis.  Hydrocele,  in  some  cases, 
extends  along  the  cord  as  high  as  the  ring,  the  swelling  at  the  same 
time  being  so  tense  that  fluctuation  is  not  perceptible.  Then  the 
origin  of  the  swelling  from  below  and  its  gradual  ascent,  its  being 
constantly  of  the  same  size,  and  the  impossibility  of  distinguishing 
the  testicle  is  indicative  of  hydrocele.  Again,  in  congenital  hernia, 
there  is  difficulty  in  distinguishing  the  testis,  as  it  is  surrounded 
within  the  same  tissue  with  the  protruded  viscera.  The  tumor  in 
this  case  is  irregular  and  extends  from  the  ring,  becomes  more  tense 
from  coughing,  can  be  separated  from  the  testis  and  permanently 
reduced ;  that  is,  it  can  be  returned  with  the  finger  when  the  pa- 
tient is  standing,  but  water  will  descend  and  fill  the  sac  even  under 
the  pressure  of  the  best-fitting  truss.  This  is  what  deceives  in  a 
complicated  case,  when  hernia  and  hydrocele  both  exist ;  but,  upon 
careful  examination,  it  will  be  found  that  the  neck  of  the  sac  is 
compressible,  and  the  sac  filled  from  below,  upward.  Watery  cysts 
in  the  spermatic  cord  may  be  distinguished  fi'om  hernia  by  the  uni- 
form surface  of  the  enlargement,  the  fluctuation,  and  the  invaria- 
bleness  of  the  size.  Circocele  is  often  mistaken  for  hernia,  by  prac- 
titioners,  and  it  is,  in  some  cases,  difficult  to  distinguish  between  an 
omental  hernia  and  a  varicose  state  of  the  spermatic  veins,  as  they 
possess  all  the  peculiarities  of  a  hernia.  Here,  again,  a  circocele  en- 
larges from  below  upward,  and  the  convoluted  veins  impress  a  pecu- 
liar vermicular  sensation,  that  a  person  having  determined  a  few 
cases  is  not  liable  to  make  a  false  diagnosis. 

Sir  Astley  Cooper  advises  that  the  patient  be  placed  in  a  recum- 
bent position  and  have  the  swelling  reduced,  and  that  the  surgeon 
should  then  press  on  the  ring  with  his  finger  and  allow  him  to  rise. 
This  precludes  the  possibility  of  the  viscera  coming  down,  but  not 
the  passage  of  the  blood  through  the  spermatic  artery. 


Hernia  —  Procidentia   Uteri,  etc.  219 

Femoral  hernia  protrudes  from  under  the  crural  arch,  and  caia  be 
readily  defined  by  the  impulse  given  from  the  femoral  artery  as  it 
passes  from  under  Poupart's  ligament,  through  the  crural  arch 
formed  by  the  inferior  edge  of  the  aponeurosis  of  the  obliquus  ex- 
ternus  abdominus.  Under  the  crural  arch  an  oval  depression  is 
found  on  the  front  of  the  thigh  on  the  surface  of  the  pectineeus 
muscle.  At  the  upper,  outer  and  lower  sides,  this  hollow  is  bounded 
by  a  sharply  defined  edge  of  the  fascia,  there  not  being  such  bound- 
ary internally.  Where  the  attachment  of  the  fascia  to  the  crural 
arch  terminates,  it  forms  a  distinct  semi-lunar  or  crescent-shaped 
fold,  covering  the  femoral  artery  and  vein. 

The  descending  viscera  under  the  arch  —  in  some  cases  the  tumor 
—  is  circumscribed  and  soft,  and  the  neck,  seemingly,  bound  down 
by  a  well-defined  encircling  edge  of  fascia.  There  is  another  form 
of  femoral  hernia  in  which  the  viscera  are  contained  within  the 
sheath  of  the  blood-vessels ;  the  protrusion,  in  that  case,  is  more 
obscure,  and  the  defined  edge  of  fascia  not  so  apparent.  This  con- 
dition of  femoral  hernia  is  rare.  The  protrusion  in  this  form  of 
hernia  is  usually  small  and  confined  to  women  —  men  being  but 
seldom  afflicted  with  it. 

Glandular  enlargements  are  liable  to  embarrass  the  inexperienced 
practitioner,  and  even  those  who  have  had  the  opportunity  of 
examining  cases  of  crural  hernia.  Patients'  lives  have  been 
compromised  by  the  surgeon  having  supposed  a  strangulated  hernia 
to  be  an  inflamed  gland.  Psoas  abscess  has  been  mistaken  for 
hernia,  as  it  partially  disappears  upon  pressure  and  will  give  an 
impulse  on  coughing.  A  varicose  condition  of  the  sapheua  vein 
tends  to  deceive  as  it  can  be  reduced  by  pressure  and  enlarges  when 
the  patient  is  in  the  erect  position.  It  must  be  observed,  however, 
that  femoral  hernia,  like  that  of  other  hernial  protrusions  (if  not 
incarcerated)  can  be  reduced  and  maintained  i-n  situ  by  means  of  a 
truss ;  and,  if  strangulated,  however  small,  it  is  attended  with  a 
most  painful  disturbance  of  the  bowels  and  induces  nausea  and 
vomiting.  These  indications  should  be  carefully  considered,  and  the 
patient  relieved  by  taxis  if  possible ;  if  not,  there  should  be  no 
delay  in  giving  relief  by  the  knife. 

HERNIA   COMPLICATED   WITH   A    RETAINED   TESTICLE. 

It  has  been  observed  in  dissections,  that  a  small  fold  of  peri- 
toneum is  continued  from  the  upper   part  of  the  testis  to  a  por- 


220  Orthopjedia. 

tion  of  the  ilium  or  the  ccecum  in  some  subjects,  and  forms  a 
preternatural  connection  between  the  parts.  The  descent  of  the 
testis  under  such  a  condition  would  inevitably  bring  the  intestine 
with  it,  and,  being  so  connected,  preclude  the  possibility  of  wearing 
a  truss,  as  the  pressure  could  not  be  borne  on  the  testicle.  The 
descent  of  but  one  testicle  into  the  scrotum  determines  in  a  measure 
this  condition  of  the  patient  when  he  cannot  endure  the  pressure  of 
a  truss.  In  some  cases  the  whole  mass  can  be  so  perfectly  reduced 
within  the  abdominal  cavity  as  to  admit  of  wearing  a  truss;  in 
others,  it  can  only  be  reduced  within  the  inguinal  canal,  and 
remains  there  for  a  time,  forming  a  bubonocele.  In  other  cases  a 
bubonocele  may  be  observed  and  the  descent  of  only  one  testicle. 
If  no  inconvenience  arises,  a  truss  should  not  be  applied,  as  this  is 
usually  observed  in  children,  the  testis  may  descend  into  the  scro- 
tum, or  so  plug  the  canal  as  to  prevent  a  descent  of  the  intestine. 
Mr.  Pott  describes  these  cases  as  of  frequent  occurrence  and  most 
difficult  of  treatment ;  and  this  agrees  with  our  experience  in  the 
treatment  of  several  hundred  cases  of  hernia,  annually  for  the  past 
twenty  years. 

To  obtain  a  tolerably  satisfactory  diagnosis  of  hernial  protrusion, 
it  is  essential  to  obtain  a  history  of  the  ailment,  then  the  symp- 
toms and  peculiarities  attending  the  case,  and,  if  no  urgent  symp- 
toms present,  and  a  tumor  exists  that  can  be  reduced  and  retained 
by  means  of  a  well-fitting  truss,  no  further  efforts  are  required  for 
the  safety  of  the  patient. 

PROGXOSIS. 

The  necessity  for  wearing  a  truss  is  imperative,  in  most  instances, 
to  the  saving  of  the  life  of  the  individual  laboring  under  a  hernia  — 
even  of  the  smallest  dimensions.  Small  protrusions  are  the  more 
liable  to  become  strictured,  and  this  is  the  opinion  of  our  most 
reliable  writers  on  the  subject  of  hernia:  as  Scarpa,  Potts,  Hey, 
Astley  Cooper,  Lawrence  and  Wood. 

To  obtain  a  tolerable  prognosis  of  a  case  of  hernia  is  to  ascertain 
the  age  and  condition  of  the  patient,  the  date  of  the  protrusion,  if 
it  is  free  or  not  free  from  stricture  or  inflammation,  the  symptoms 
which  attend  it,  and  the  possibility  of  its  reduction  —  including  all, 
if  any,  peculiar  circumstances  attending  it. 

If  the  subject  is  an  infant,  the  case  is  seldom  attended  with  any 
serious  consequences.      The  pliability  of  the  tissues  admit  of  the 


Hernia,  Procidentia  Uteri,  etc.  221 

read}^  reduction  of  the  viscera,  yet  there  is  danger  in  permitting 
them  to  remain  without  a  truss.  The  tendency,  even  when  very 
young,  is  for  the  aperture  to  become  small  if  the  protrusion  is 
frequently  redressed  and  partially  retained  by  the  tight  fastening 
of  the  diaper;  from  this  circumstance,  there  is  danger  of  strangula- 
tion of  the  contents  of  the  hernial  sac,  which  may  be  produced  by 
some  violent  forcing,  as  that  of  choking,  coughing,  or  crying  vigor- 
ously. Strangulations  have  taken  place  in  children  of  six  months, 
and  have  caused  their  death  —  not  having  been  discovered  by  the 
mother,  as  the  protrusion  was  very  small,  and  only  detected  by  the 
surgeon  when  too  late  to  save  life  by  an  operation. 

Adults  in  the  vigor  of  life,  laboring  under  hernia,  are  in  a  more 
critical  condition,  if  neglectful  or  subjected  to  mal-treatment,  than 
the  very  young  or  the  aged.  The  danger  arises  from  the  suscepti- 
bility to  inflammation  in  the  protruded  intestine  resulting  in 
stricture.  In  people  in  the  decline  of  life  there  is  not  that  degree 
of  danger  in  permitting  the  protrusion  to  remain.  Their  languid 
circulation  renders  them  less  liable  to  inflammation,  and  their 
rupture  is,  mostly,  of  long  standing,  the  aperture  enlarged,  and  the 
■edges  indurated  from  frequent  reduction  of  the  contents. 

in  recent  rupture,  or  in  cases  where  it  has  been  of  long  duration, 
and  secured  by  wearing  a  truss,  the  protrusions  arc  extremely  liable 
to  stricture,  because  of  the  diminished  size  of  the  aperture.  Protru- 
sions of  large  size  and  of  long  standing,  it  is  not  always  Avell  to 
reduce.  It  is  only  necessary  to  sustain,  and  prevent  the  increasing 
tendency  to  enlargement,  as  in  cases  of  scrotal  hernia,  which,  we 
are  credibly  informed  have  extended  to  the  knee  and  were  of 
extraordinary  size.  To  attempt  to  retain  a  hernia  of  much  less  size 
■even,  would  require  such  force  from  the  springs  of  a  truss  as  to  be 
unendurable.  And  another  difficulty  arises  from  an  attempt  at 
reducing  large  protrusions  of  long  standing:  nausea  and  vomiting 
is  produced  to  an  unbearable  extent.  There  is  a  possibility  of 
reducing,  by  degrees,  large  hernias,  unbilical  more  especially ;  and 
we  have  succeeded  in  such  cases  to  the  great  relief  of  the  patient 
■  from  the  chafing  and  excoriation  of  the  projecting  mass,  by  the 
gradual  increase  of  a  supporting  bandage. 

The  contents  of  the  hernial  sac  invite  special  attention  in  regard 
to  a  proper  diagnosis,  tending  to  the  relief  of  j)atients  who  have 
had  little  or  no  inconvenience  from  large  hernias  of  long  standing, 
when  they  are  suddenly  seized  with  symptoms  of  a  strangulation  in 


222  Or  thop^edia  . 

the  part.  This  condition  of  the  patient  arises  from  the  existence 
of  omental  protrnsion  only  during  the  time  previous  to  the  severe 
symptoms.  This  condition  predisposes  to  an  escape  of  a  portion  of 
intestines,  which  descends  and  hecomes  more  or  less  constricted  and 
painful,  and  which  if  not  nearly  reduced  by  ordinary  methods  no 
time  is  to  be  lost  in  having  the  x^arts  relieved  by  the  knife. 

TAXIS. 

The  reduction  of  hernia  by  the  hand,  requires  much  practical 
experience  ;  as  the  attempt  at  reduction  may  increase  the  unfavor- 
able condition  of  the  patient. 

Patients  seldom  call  upon  a  surgeon  to  reduce  a  hernia  if  not 
alarmed  at  their  inability  to  reduce  it,  and  the  suffering  caused 
thereby ;  hence,  the  parts  are  in  an  irritable  condition,  and  an 
increase  of  that  tendency  must  be  avoided  if  possible. 

The  difficulty  may  exist  under  various  phases  of  the  ailment. 
The  enlargement  of  a  portion  of  the  omentum  or  intestine  in  a  con- 
tracted aperture,  and  attended  with  suffering  from  some  cause  of 
irritation  is  one,  and  under  such  circumstances,  an  attempt  should 
be  made  to  allay  the  excitement  in  the  part,  and  not  increase  it  by 
handling.  The  symptoms  are  a  swelling  in  the  groin,  scrotum,  or 
crural  arch,  sensitive  to  the  touch;  if  an  intestinal  hernia  it  is 
usually  most  painful  and  the  pain  increased  by  coughing,  sneezing, 
or  standing  upright.  These  are  the  first  indications  of  an  increasing 
tendency  to  a  more  serious  condition:  as  nausea,  and  inability  to 
evacuate  the  bowels  per  anum.  When  in  this  condition  the  hernia 
is  said  to  be  incarcerated,  and  if  relief  is  not  soon  afforded  the- 
suffering  patient,  death  will  soon  ensue.  The  prolapsed  viscera  are 
constricted  and  greatly  congested,  and  the  relief  is  dependent  upon 
the  return  of  the  viscus,  freed  from  compression.  This  can  only 
be  accomplished  by  returning  the  bowel  into  the  abdomen  by  taxis, 
or  dividing  the  parts  which  form  the  stricture. 

For  the  reduction  of  hernial  protrusions  much  advantage  is 
obtained  from  a  favorable  position  of  the  patient,  which,  by  the  way, 
is  the  preparatory  step.  The  j)atient  having  been  stripped  of  all 
clothing  that  could  interfere  in  the  handling,  should  be  so  placed 
upon  his  back  as  to  admit  of  the  hips  being  elevated  above  the 
shoulders,  about  twelve  or  fifteen  inches.  This  position  was  first 
attempted  by  Winslow,  and  greatly  approved  of  by  Sir  A.  Cooper 
The  thighs  are  then  flexed  towards  the  body;  this  position  relaxes 


Hernia,  Procidentia  Uteri,  etc.  223 

the  fascia  of  the  thigh,  also  the  aperture  througli  which  the 
viscera  has  passed.  The  tension  being,  in  ever  so  small  a  degree, 
relieved  tends  to  abate  a  part  of  the  cause  of  irritation.  Having 
obtained  this  position  for  the  patient  —  the  suffering  being  great  — 
we  have  two  towels  doubled  and  wet  in  water,  at  a  temperature  of 
60°  Fahr.,  and  applied  over  the  lower  portion  of  the  abdomen.  The 
following  mixture  should  then  be  administered  in  half  drachm  doses 
repeated  every  ten  or  twenty  minutes,  to  meet  the  urgency  of  the 
case : 

Antim.   tart gr.  i 

Aq.  bullien 3  ii 

Tr.  opii 3  i 

Ft.  sol J* 

One  fourth  of  this  to  be  given  every  fifteen  minutes. 

This  treatment  seldom  fails  to  relieve  the  pain  before  extreme 
nausea  ensues,  and  the  pain  having  been  relieved,  we  consider  our 
patient  in  a  condition  to  have  slight  pressure  made  upon  the  pro- 
truding mass.  We  then,  first,  make  a  gentle  effort  to  grasp  the 
entire  protrusion  with  the  thumb  and  fingers  of  the  right  hand, 
holding  the  mass  tolerably  firm,  if  not  giving  pain,  for  some 
minntes,  and  then  an  efEort  to  draw  it  back  from  the  stric- 
tured  ring.  If  all  this  is  accomplished  without  complaint 
from  the  patient,  the  fingers  and  thumb  of  the  left  hand 
are  applied  to  the  neck  of  the  sac,  or  npper  portion  of  the 
protrusion,  and  gentle  pressure  made  upon  only  a  small  portion. 
If  the  protrusion  is  observed  to  diminish  under  pressure  after  a  few 
minutes,  the  patient  is  safe;  the  whole  mass  will  be  reduced  after  a 
reasonable  time,  if  this  procedure  is  carefully  observed.  The  attempt 
to  press  the  whole  mass  up  at  once  usually  fails.  If  the  patient 
complains  under  the  efforts  made  at  reduction,  we  desist  for  a  longer 
time,  keeping  the  towels  wet  and  giving  the  solution  until  nausea 
tends  to  vomiting.  The  patient  may  remain  in  position  for  several 
hours,  and  if  relief  is  not  afforded  by  these  means,  we  then  have 
resort  to  an  anaesthetic,  and  the  taxis  again  attempted  —  carefully 
avoiding  the  use  of  much  force,  as  nothing  is  gained  thereby  and 
injury  is  to  be  apprehended.  When  the  protruded  mass  is  grasped 
it  must  be  retained  firmly,  and  the  pressure  can,  in  most  cases,  be 
increased  without  giving  pain  if  steadily  maintained  —  in  fact,  the 
grasp  should  be  continued  as  long  as  the  strength  in  the  fingers  will 


224  Or  th  opjebia. 

admit,  as  we  have  often  witnessed  the  rednction  progressing  favor- 
ably when  we  were  quite  exhansted,  and  observed  it  again  increase  in 
size  npon  the  withdrawal  of  pressure.  An  intelligent  assistant  is  of 
great  service  under  such  circumstances.  The  direction  of  pressure 
in  the  application  of  taxis  to  inguinal  hernia,  other  than  npward, 
we  have  never  found  to  be  of  any  advantage,  although  obliquely 
outward  is  advised  by  Sir  A.  Cooper,  Lawrence,  and  others.  In 
femoral  hernia  it  is  of  some  service  to  lift,  as  it  were,  the  mass  off 
of  Poupart's  ligament  and  bear  it  outward  and  below.  If  pressed 
upward,  in  the  position  it  is  usually  found,  it  is  to  prevent  its  return 
by  keeping  it  doubled  over  the  ligament.  Much  advantage  is 
obtained  in  the  rednction  of  femoral  hernia  by  adducting  the  flexed 
thigh.  This  relaxes  the  femoral  fascia,  and  tendon  of  the  external 
oblique  muscle,  and,  in  some  cases,  relieves  the  patient  of  pain. 
T''he  same  care  to  avoid  severe  pressure  from  the  hand  should  be 
observed  in  reducing  femoral  hernia  as  in  that  of  inguinal. 

Mr.  Hey  remarks  (''Practical  Observations  in  Surgery")  on  the 
use  of  the  warm  bath  for  the  reduction  of  strangulated  hernia :  "  I 
have  often  seen  it  useful ;  but  I  have  also  often  seen  it  fail  of  suc- 
cess. Whenever  it  is  used  in  this  disease  the  patient  should  be 
placed,  if  possible,  in  a  horizontal  position.  Gentle  efforts  with  the 
hand  to  reduce  the  prolapsed  part  are  perhaps  attended  with  less 
danger  and  with  greater  prospects  of  success  while  the  patient  lies 
in  the  bath  than  in  any  other  position.  The  free  use  of  opiates 
coincides  with  that  of  warm  bathing,  and  under  some  circumstances, 
these  means  deserve  to  be  tried." 

One  noted  authority  among  the  old  writers  on  the  subject  of  her- 
nia (Wilmer),  strongly  recommended  the  application  of  coJd  to  the 
protrusion,  and  this  procedure  is  approved  by  most  of  the  modern 
surgeons,  often  with  that  of  tobacco  injections,  which  ought  to  be 
used  with  great  caution  ;  as  patients  have  died  from  its  poisonous 
influence.  Cold  applications  in  the  form  of  ice  were  particularly 
recommended  by  Benjamin  Bell.  The  best  way  is  to  pound  the  ice, 
tie  it  up  in  a  bladder,  and  place  it  on  the  rupture.  When  ice  cannot 
be  procured.  Sir  A.  Cooper  recommends  a  mixture  of  equal  parts  of 
nitre  and  sal  ammonia  —  ten  ounces  of  the  mixture  to  be  added  to 
one  pint  of  water  in  a  bladder.  This  eminent  authority  gives  this 
further  reliable  advice :  "  That  if  after  four  hours  the  symptoms 
become  mitigated  and  the  tumor  lessens,  this  remedy  may  be  per- 
severed in  for  some  time  longer,  but  if  they  continue  with  unabated 


Hernia,  Procidentia  Uteri,  etc.  225 

violence,  and  the  tumor  resists  every  attempt  at  reduction,  no  fur- 
ther trial  should  be  made  of  the  application."  [On  inguinal  and  con- 
genital hernia]. 

This  acknowledged  skilful  surgeon  (skilful  more  especially  in 
intricate  surgical  operations)  advises  much  greater  perseverance  in 
the  use  of  other  means  than  is  generally  practiced.  We  have 
labored  three  and  four  hours  to  reduce  a  strangulated  hernia  with- 
out, apparently,  making  the  slightest  favorable  impression,  and 
finally  succeeded  in  our  efforts  —  in  fact,  but  seldom  fail,  except 
in  cases  where  adhesion  to  the  surrounding  tissue  had  taken  place. 
As  patients  have  been  relieved  of  all  of  the  painful  symptoms  of 
strangulated  hernia  by  treatment  —  previously  stated  —  and  free 
evacuations  followed  the  relief,  the  protrusion  only  rendered  less 
tense  and  void  of  pain,  and  the  size  apparently  not  diminished, 
therefore  it  is  obvious,  that  it  is  possible  to  relieve  strangulated  her- 
nia when  incarcerated,  and  that  the  effort  should  be  made  when 
perfectly  convinced  of  the  incarcerated  condition  of  the  protrusion. 

As  before  stated,  the  hernia  may  consist  of  omentum  that  has  be- 
come incarcerated,  and  at  no  time  previously  found  to  be  troublesome, 
but  from  some  unfavorable  circumstance  a  portion  of  the  intestine 
has  been  forced  through  the  neck  of  the  sac,  and  becomes  inflamed 
and  swollen,  exciting  the  ring  to  contract.  In  this  condition, 
induced  by  accident,  from  persevering  in  the  treatment  the  inflam- 
mation has  been  subdued,  the  swelling  and  consequent  irritation 
diminished,  to  there  turn  off  the  intestine;  but  for  the  accomplish- 
ment of  all  this  several  hours  of  anxious  labor  is  required  in  most 
cases.  The  several  means  we  have  described  for  the  reduction  of 
strangulated  hernia  by  taxis,  we  have  witnessed  and  practiced,  and 
speak  of  them  as  being  more  or  less  efficient,  but  there  are  others 
worthy  of  consideration  and  trial.  In  the  British  Medical  Journal, 
December  23,  1871,  p.  734,  Dr.  Philip  Crampton  Smyly,  Surgeon  to 
the  Meath  Hospital,  England,  makes  a  statement  as  follows  :  "  The 
objects  to  be  attained  in  the  treatment  of  hernia  in  a  state  of  stran- 
gulation, are  the  release  of  the  protruded  parts  from  stricture,  and 
their  replacement  within  the  abdomen,  provided  they  are  in  a  suit- 
able condition.  These  objects  are  usually  sought  to  be  accomplished 
either  by  taxis,  or  operation  with  the  knife.  Some  years  ago  a  nurse 
in  one  of  the  medical  wards  in  the  Meath  Hospital  had  a  reducible 
femoral  hernia.  She  neglected  to  wear  a  truss,  and  one  day  it 
consequently  became  stranguh^ted.     My  father,  being  the  surgeon 


226  Orthop^dia. 

on  duty,  tried  taxis,  as  did  also  other  surgeons,  without  success 
After  consultation,  an  operation  was  decided  on,  but  every  argu- 
ment failed  to  persuade  the  patient  to  submit.  She  would  rather 
die  than  be  cut.  After  the  surgeons  had  left,  the  clinical  clerk 
(since  a  very  distinguished  medical  officer  in  the  army)  and  I, 
thought  it  a  good  opportunity  to  study  the  relation  of  the  ring  to 
the  sac.  The  result  of  our  examination  not  a  little  surprised  us. 
In  withdrawing  my  finger  from  the  ring  into  which  I  had  inserted 
it,  we  heard  a  distinct  gurgle.  My  fellow  student  pressed  the  tumor, 
and  it  passed  into  the  abdomen.  The  patient  lived  for  many  years 
afterward,  and  performed  her  duties  in  the  hospital.  I  have  since 
frequently  tried  to  repeat  this  happy  manoeuvre,  and  with  most 
satisfactory  result. 

'•For  inguinal  hernia  in  the  male,  the  index  finger  is  applied  to 
the  lower  part  of  the  scrotum.  This  is  invaginated  (as  in  Wiitzer's 
operation  for  radical  cure),  the  finger  being  passed  behind  the 
testicle  and  carried  up  to  the  external  ring.  The  hernial  tumor  is 
then  pressed  downward  over  the  finger  toward  the  back  of  the 
hand,  so  as  to  make  the  strictures  in  the  ring  tense,  and  conse- 
quently smaller.  The  invaginating  finger  is  then  forced  firmly 
upward  and  outward  in  the  direction  of  the  internal  ring.  As  soon 
as  the  finger  is  firmly  grasped,  the  hand  should  be  slightly  turned, 
and  the  finger  pushed  toward  the  middle  line.  Considerable  force 
may  be  safely  applied  in  this  way,  as  all  the  delicate  structures  are 
behind  the  finger,  which  acts  mainly  on  the  stricture.  On  with- 
drawing the  finger,  the  hernia  can  usually  be  easily  returned.  The 
same  principle  is  equally  applicable  to  femoral  hernia.  This  plan, 
may  have  occurred  to  others;  but  if  so,  it  is  perhaps  not  generally 
known,  and  any  suggestions  by  which  a  cutting  operation  may  be 
safely  avoided  is  acceptable  to  the  practical  surgeon.  My  colleague, 
Mr.  Porter  (surgeon  to  the  queen  in  Ireland),  was  much  pleased  with 
the  success  of  this  plan  in  a  case  of  inguinal  hernia  strangulated 
four  days;  and  he  has  since  tried  it  himself  with  satisfactory 
result. 

•'•'The  advantages  which  I  claim  for  "this  procedure  are:  1.  The 
strangulating  portion  of  the  ring  is  dilated  before  any  pressure  is 
applied  to  the  bowel.  2.  Much  greater  force  may  be  applied  to 
dilate  than  could  safely  be  brought  to  bear  when  the  intestine  itself 
is  employed  for  dilatation,  as  in  ordinary  taxis.  3.  There  is  much 
greater  probability  of  returning  the  bowel  into  the  abdomen  in  a 


Hernia,  Procidentia  Uteri,  etc.  227 

good  condition,  and,  consequently,  in  a  number  of  cases  avoiding  a 
dangerous  surgical  operation." 

Another  auxiliary  tending  to  the  reduction  of  strangulated  hernia 
is  presented  by  Thomas  Bryant,  Esq.,  surgeon  to  Guy's  Hospital,  in 
the  Medical  Times  and  Gazette,  April  30,  1872.  This  gentleman  was 
called  upon  by  Mr.  Kelson  Wright,  of  Kennington,  to  see  with  him 
a  case  of  strangulated  hernia  in  an  old  man,  aged  71.  "  He  had 
been  the  subject  of  a  right  scrotal  hernia  for  thirty  years,  and  had 
worn  a  truss.  He  had  had  occasional  difficulty  in  its  reduction 
after  its  descent;  but  Mr.  Wright  had  always  succeeded  in  reducing 
it.  On  this  present  occasion  the  same  effort  had  failed,  and  when 
I  saw  him  vomiting  had  existed  for  two  days,  and  a  large  hernia 
existed  in  the  right  side  of  the  scrotum,  one  portion  of  it  felt  tenser 
than  the  other.  Chloroform  was  given,  and  the  taxis  employed, 
but  without  success;  consequently  herniotomy  was  performed,  it 
being  necessary  to  expose  the  bowel.  When  this  was  done  the 
coecum  escaped,  dragging  down  with  it  some  three  inches  of  small 
intestine  covered  with  j)eritoneum — the  external  ring  pressing 
firmly  upon  it.  With  some  difficulty  the  bowel  was  returned,  the 
wound  brought  together,  and  the  whole  carefully  bound  together 
by  means  of  a  pad  and  spica  bandage.  A  morphia  .suppository  was 
given. 

During  the  night,  however,  the  old  man  would  get  out  of  bed, 
and  in  the  attempt  he  tore  off  all  the  dressings.  As  a  consequence, 
the  bowel  came  down  again  ;  vomiting  returned,  with  abdominal 
pain.  Mr.  Wright  was  sent  for,  but  all  his  efforts  to  return  the  in- 
testine were  fruitless.  I  was  consequently  sent  for.  I  found  the  old 
man  lower  than  when  I  saw  him  before.  The  hernia  was  larger  than 
ever.  I  gave  him  chloroform,  and  attempted  reduction,  but  failed. 
I  then  increased  the  opening  at  the  internal  ring;  but  on  doing 
this  more  large  intestine  came  down,  and  no  effort  of  mine  could 
reduce  it.  I  consequently  punctured  the  intestine  in  four  or  five 
places  with  a  grooved  needle,  and  let  off  the  wind ;  this  measure 
enabled  me  to  do  what,  under  other  circumstances,  I  could  not  do 
—  reduce  the  hernia.  The  wound  was  then  re-adjusted,  and  a  good 
pad  firmly  secured  on  Avith  strapping,  opium  being  given;  and  I 
am  pleased  to  add,  no  one  bad  symptom  folloAved  these  rough 
measures,  and  a  good  recovery  ensued.  Mr.  Wright  tells  me  the 
wound  united  without  a  drop  of  pus  appearing —  the  whole  uniting 
by  primary  union. 


228  Orthof^dta. 

"  It  was  interesting  to  note  that  when  the  bowel  was  punctni-ed 
nothing  but  wind  escaped,  except  in  one  spot,  where  the  smallest 
drop  of  blood  oozed  out,  evidently  from  the  congested  intestinal 
wall.  Xone  of  the  contents  of  the  intestines  escaped  even  after  the 
rough  manipulation  to  whicli  they  were  subjected." 

This  eminent  surgeon  further  remarks :  "  I  punctured  four  or 
five  times  (that  is  the  bowel),  until  I  had  reduced  the  whole  of  it. 
No  faeces  escaped  whatever,  although  during  the  whole  of  this  time 
I  was  so  manipulating  the  intestine  that  if  it  was  possible  anything 
could  come  out  it  would  have  done  so.  .  After  the  patient  recovered 
I  asked  myself  the  question  :  If  the  large  intestine,  exposed  to  view 
as  that  was,  and  not  supported  in  any  way  by  the  abdominal  walls 
and  contents,  could  be  tapped  without  any  escape  taking  place, 
-surely,  Avhere  the  intestine  is  supported,  the  risk  of  extravasation 
would  be  greatly  diminished  by  the  natural  support  given  to  it  in 
the  abdominal  cavity  ?  I  think  we  must  draw  this  conclusion, 
then  :  that  there  are  cases  in  whicli  you  may  puncture  the  intes- 
tine freely,  and  with  every  prospect  of  affording  great  relief.  In 
hernia,  this  case  clearly  proves  that  you  may  resort  to  it,  and  I  be- 
lieve you  had  better  adopt  it  if  there  be  much  trouble  in  returning 
it  very  large  hernia.  Had  I  learned  this  lesson  earlier,  I  should 
have  tapped  long  before  I  did.  But  might  we  not  employ  this 
treatment  much  earlier  ?  If,  after  operating,  we  can  reduce  a 
strangulated  hernia  by  pricking,  which  we  could  not  reduce  with- 
out, is  it  not  possible  that  we  might  reduce  some  hernia  without 
any  operation  at  all  ?  Consider  a  small  enterocele.  See  the  intes- 
tine bulging  beyond  the  neck  of  the  sac  and  becoming  congested. 
See  how  it  becomes  strangulated  and  congested  if  reduction  is  not 
effected.  If  you  tap  it  you  let  out  all  the  wind,  the  whole  of  the 
knuckle  of  intestine  collapses,  and  you  get  only  a  little  flaccid  lump. 
Under  these  circumstances,  what  is  there  to  prevent  the  bowel 
being  replaced  by  natural  agency  ?  I  confess  my  liking  for  the 
idea  from  the  surgical  point  of  view.  I  think  it  is  scientifically 
correct,  and  I  see  nothing  to  prevent  it  having  the  desired  effect. 
I  cannot  recommend  it  practically,  because  I  have  had  no  experi- 
ence of  it ;  but  I  intend  to  test  the  value  of  it  when  a  suitable  case 
comes  before  me.  And  what  would  constitute  a  suitable  case? 
]Srot  those  slight  cases  where  you  can  return  the  intestine  without 
opening  the  sac,  because  we  know,  as  a  rule,  they  do  well.  But'  I 
certainly  will  try  it  in  those  cases  of  hernia  that  we  not  infrequently 


Hernia,  Procidentia  TJteri,  etc.  229 

get  in  hospital,  and  sometimes  in  private  practice  —  large  scrotal 
hernia,  and  large  umbilical  hernia,  the  interference  with  which  is 
nearly  always  followed  by  death.  It  is  quite  exceptional  for  a  large 
inguinal  or  umbilical  hernia  to  recover  after  herniotomy  when  the 
sac  has  been  opened.  By  opening  the  sac  I  mean  not  only  just  at 
the  neck,  but  complete  exposure  and  manipulation  of  the  contents." 

Entertaining,  as  we  do,  a  most  favorable  view  of  this  novel  means 
of  reducing  strangulated  hernia,  they  both  having  succeeded  under 
the  most  trying  circumstances,  present  to  us  a  consideration  of 
sufficient  inducement  to  give  them  a  trial  in  apparently  suitable 
oases,  and  without  eutertaining  much  ajoprehension  of  inflicting 
serious  injury  to  the  patient. 

We  would,  however,  suggest  that,  in  the  invaginating  process, 
the  propriety  (if  not  an  improvement)  of  using  distending  forceps 
for  the  overcoming  of  the  constricting  ring.  An  instrument  made- 
for  the  purpose,  that  would  do  less  violence  to  the  implicated  tissues 
than  that  of  thrusting  the  finger  within  the  constricted  aperture.. 
For  this  purpose,  we  would  suggest  the  construction  of  a  pair  of 
forceps,  for  the  distension  of  the  constricting  parts  in  strangulated 
hernia,  and  of  the  following  form  :  A  pair  of  hinged  forceps  about 
six  inches  in  length,  terminated  with  thin  rounded  ends  a  third 
of  an  inch  wide,  slightly  hollow  or  grooved  within  the  blade,  of 
equal  thickness;  and  thin,  but  not  sharp  to  endanger  the  cutting 
of  the  invaginated  integument.  And  at  about  one-third  of  the 
length  of  the  blades  from  the  hinged  end,  to  be  of  such  thickness 
as  to  admit  of  the  adjustment  of  a  screw  through  one  of  the  blades. 
By  means  of  this  screw  a  graduated  distention  of  the  ring  could 
be  carefully  controlled.  And  in  cases  of  small  protrusion  of  viscera,, 
or  when  relieved  of  distension  from  flatus  by  tapping,  one  blade 
could  be  entered  above  and  the  other  below;  and  the  instrument 
made  to  distend  the  aperture  without  impinging  upon  the  pro- 
truding viscera.  This  would  afford  perfect  safety  to  the  patient,, 
and  a  means  of  making  ample  distension  for  the  reduction  of  the 
bowel  to  within  the  abdomen. 

The  effort  by  taxis  in  the  ordinary  way  of  forcing  the  protruded 
viscera,  congested  and  inflated,  through  the  irritated,  and  conse- 
quently constricted  ring,  must  be  considered  as  a  violent  procedure 
even  under  the  most  skilful  treatment.  The  very  pressure  of  the 
protruded  viscera  made  against  the  ring  increases  the  recently  con- 
stricting tendency  to  the  increase  of  the  obstructed  circulation  io 


230  Orthop^bta. 

the  protruded  mass.     This  may  be  avoided  by  these  new  and  appar 
ently  feasible  methods,  and  in  many  instances  save  the  patient  from 
the  hazardous  operation  of  herniotomy  that  has  proved  fatal  in 
many  cases. 

THE  COXSTEUCTIOX  AXD  APPLICATION  OF  TRUSSES  FOR  THE    RELIEF 
OF   ABDOMIIs^AL   HERNIA. 

Therapeutic  agents  for  the  retention  of  replaced  viscera  have 
not  been  considered  by  surgeons  in  general,  of  as  much  im- 
portance as  the  pathological  condition  actually  demands.  The 
surgico-mechanical  appliances  commonly  denominated  trusses,  are 
mainly  devised  and  applied  by  the  mechanics  that  construct  them. 
These  adventurers  obtain  favorable  notice,  most  frequently  from 
some  novel  device  in  the  construction  of  a  peculiar  pad  or  the 
means  of  attaching  it  to  the  spring  that  encircles  the  body,  and,  by 
the  favorable  notice  given  them  from  eminent  surgeons,  amass  for- 
tunes from  the  sale  of  their  device  to  the  great  number  thus  afflicted 
with  hernia  —  about  every  tenth  person.  This  immense  traffic  is, 
because  of  its  equally  large  profits,  truly  a  very  great  inducement  to 
efforts  at  introducing  useless  complications,  and  the  fabrication  of 
absolute  falsehoods  concerning  them,  as  a  certain  means  of  radical 
cure.  By  these  means  they  obtain  extravagant  prices  for  appliances 
of  no  peculiar  merit.  This  is  greatly  to  be  deplored  when  we  con- 
sider the  critical  condition  of  the  patient,  and  their  reliance  upon 
their  medical  adviser's  statement,  that  the  greatest  possible  security 
will  be  afforded  them  in  the  purchase  of  one  of  these  supposed  im- 
proved trusses. 

There  is  no  one  form  of  truss,  or  uniformity  of  pad,  that  will 
meet  all  of  the  varied  conditions  of  patients  laboring  under  the  several 
varieties  of  hernia.  This  must  be  readily  comprehended  by  every 
experienced  and  reflecting  medical  practitioner.  Yet,  the  patient 
is  often  inconsiderately  recommended  to  the  truss-maker  that  has 
attained  the  greatest  notoriety  for  the  peculiarity  of  his  truss  of 
fixed  form  —  precluding  the  possibility  of  adaptation  to  an  extra- 
ordinary case  and,  consequently,  a  failure  in  retaining  viscera  in 
situ  when  applied.  Some  of  these  trusses  having  small  obtuse, 
conical  pads,  are  applied  to  patients  greatly  attenuated  and  the 
hernial  aperture  thereby  greatly  distended  from  this  concentrated 
force.  This  form  of  pad  is  also  applied  to  inguinal  or  femoral 
hernia,  or  to  an  infant,  or,  most  corpulent  person  that  may  require 


Hernia,  Procidentia  Uteri,  etc.  231 

II  truss.  This  is  by  no  means,  in  a  surgical  sense,  meeting  the  indi- 
cations that  present,  as  in  all  other  ailments  that  obtain  the  skill  of 
the  surgeon.  And  why  not  ?  The  condition  of  the  patient  having 
a  hernia,  is  considered  by  the  most  eminent  in  the  profession,  as 
truly  perilous,  and  much  more  so  than  many  other  ailments,  to 
which  a  surgeon  would  give  very  especial  attention,  and  that  do  not 
so  imperil  the  patient's  life  as  that  of  a  reducible  hernia;  which, 
from  unskilful  treatment  can  become  strangulated.  When  that 
alarming  condition  has  ensued,  then  the  utmost  skill  is  devoted  to 
the  patient,  when  it  might  easily  have  been  prevented  by  the  use  of 
properly  devised  surgical  appliances. 

In  hernia,  as  in  all  other  pathological  conditions  of  the  system, 
certain  indications  present  for  the  consideration  of  the  student  of 
anatomy  and  surgery.  The  latter  has  probably  been  as  carefully 
studied  as  in  any  other  ailment  afflicting  the  body  of  man  ;  but  has 
been  mainly  confined  to  the  abnormal  condition  of  the  protruded 
viscera  requiring  surgical  treatment  when  irreducible  by  taxis,  and 
not  extended  to  appliances  for  the  relief  of  reducible  hernia.  To  such 
palliative  and  preventive  means  there  has  been  an  actual  indiffer- 
ence—  submitting  the  precarious  condition  of  patients  to  adven- 
turous treatment,  which,  under  the  most  favorable  circumstances, 
is  to  comj)romise  the  life  of  the  unfortunate  individual  laboring 
under  reducible  hernia.  That  it  is  of  rare  occurrence  for  persons' 
lives  to  be  endangered  by  wearing  ordinary  trusses  is  not  a  mitigat- 
ing argument  for  the  indifiFerence  of  surgeons  when  they  are  profes- 
sionally consulted.  It  involves  them  in  a  responsibility  for  the 
patient's  future  condition.  The  patients,  from  prudential  motives, 
having  confidence  in  their  professional  attainment,  intrust  their 
lives  to  their  protection.  The  surgeon  is  in  duty  bound,  to  the  best 
of  his  ability,  to  tender  his  patient  security  from  uncertain  treat- 
men  t. 

The  construction  of  a  truss  demands  surgical  skill,  and  a  care- 
ful consideration  of  the  indications  that  present  in  the  various 
pathological  phases  of  hernia. 

Hernia  is  the  result  of  a  predisposition,  in  most  cases,  and  induced 
most  frequently  from  violence  or  a  continued  tendency  to  a  protru- 
sion of  the  viscera  through  existing  apertures,  abnormally  distended, 
or,  in  rare  instances,  injury  separating  muscular  continuity  and  not 
confined  to  any  particular  locality. 

In  the  first  condition  tending  to  hernia,  is  the  erect  attitude  of 


232  ORTROPyEBIA. 

man,  relaxed  muscular  fibre,  exhausting  influence  —  as  sickness,  or 
from  long  continued  labor,  one  of  the  most  common  causes  of  her- 
nia ;  as  gravity  obtains  an  ascendency  over  the  vital  energies  of  the 
body,  tending  to  hernia,  prolapsus  ani,  procidentia  uteri,  retroversion, 
hemorrhoids  and  varix. 

To  our  protection  from  hernia,  hoAvever,  there  is  a  special  provis- 
ion by  a  tendinous  expansion  from  the  external  oblique  muscles 
that  sustain  the  whole  hypogastric  region  when  not  in  a  relaxed 
condition.  This  tendinous  expansion,  strengthened  by  interlacing 
of  texture,  supports  immense  tumors,  dropsical  accumulations, 
and  other  distending  forces  of  circumscribed  spherical  masses.  But, 
in  the  most  pendent  portion  of  the  abdomen  Ave  have  the  passages 
for  the  spermatic  cord  in  the  male,  and  the  round  ligament  in  the 
female,  the  intestines  and  omentiim  extending  floating  masses, 
unfavorable  circumstances  so  disposing,  admit  of  portions  entering 
these  yielding  apertures. 

The  first  and  most  common  cause  tending  to  hernia,  is  a  structu- 
ral laxity  of  the  visceral  attachments,  tending  to  elongate  ;  preter- 
naturally  large  openings  of  the  abdominal  rings,  and  a  ready  yielding 
of  the  margins  of  the  apertures,  often  from  the  relaxed  condition 
of  the  abdominal  muscles. 

The  predisposition  in  patients  exists  before  hernia  has  ensued,  and 
presents  the^rs^^  indication  to  be  met  in  the  construction  of  a  truss. 
The  pendent  portion  of  the  abdomen  should  be  supported  and  the 
superincumbent  weight  of  the  abdominal  viscera  sustained  above 
the  inguinal  and  femoral  regions.  Suffering  is  suggestive  of  means 
for  relief;  and  this  will  be  observed  in  the  ruptured  laborer  when 
unable  to  get  a  truss;  he  girts  his  belt  tightly  about  his  loins  and 
is  thus  enabled  to  do  light  Avork.  The  leather  belt  of  the  laborer 
is  not,  hoAvever,  a  suitable  material  for  a  truss  belt.  It  is  uoav  the 
opinion  of  reliable  authority  that  only  suitably  sized  tempered  steel 
will  serve  to  construct  the  partially  encircling  belt  of  the  truss, 
vs^hich  also  serves  for  a  reliable  basis  of  support  under  the  varied 
conditions  of  the  body;  retaining  its  position  Avith  great  certainty, 
being  readily  adapted  to  the  body  and  maintaining  an  elastic 
resistance. 


Hernia,  Procidentia  Uteri,  etc. 


233 


Figure  91  represents  the  forms  of    single,  double,  and  child's 
truss. 
What  we  consider  the  proper  form  and  encircling  length  of  the 
Pig_  9j_  spring,  is  to  encircle  three-fourths  of  the 

circumference  of  the  pelvic  portion  of 
the  body,  one  inch  below  the  anterio- 
superior  spinous  process  of  the  ilium, 
the  posterior  limb  of  the  spring,  or  por- 
tion to  cross  the  back,  to  have  an  advance 
of  two  inches  beyond  that  of  the  anterior 
limb  which  should  pass  over  and  above 
the  pubis  to  two  or  three  lines  beyond 
the  internal  abdominal  ring,  and  above 
it.  It  will  be  observed  that  the  spring 
crosses  the  back  higher  than  that  of 
ordinary  trusses,  hence,  is  less  liable  to 
be  displaced  by  the  action  of  the  glutei 
muscles,  and  is  rendered  secure  in  position  from  being  under  the 
crest  of  the  ilium  in  its  curve  round  the  hip,  tending  to  the  most 
fixed  position  that  it  is  possible  to  place  a  truss  on  a  patient.  The 
springs  are  covered  with  some  suitable  material  and  supplied 
with  a  strap  to  complete  the  circle  around  the  hips.  This  gives 
the  desired  support  to  the  pendent  portion  of  the  abdomen 
and  above  the  apertures  through  which  the  viscera  escape.  The 
second  indication  to  be  met  is  the  securing  of  the  viscera  iji 
siYM  by  closing  the  apertures  —  an  important  and  often  the  most 
difficult  part  of  constructing  a  truss.  The  pad  must  be  made 
to  perfectly  coaptate  to  the  hernial  parietes,  which  vary  greatly 
in  different  persons,  and  in  the  location  of  the  hernia.  It  is 
impossible  to  construct  a  truss  with  one  form  of  pad  that  will 
in  every  case  retain  the  viscera  that  tends  to  protrude  even 
in  the  same  form  of  hernia.  A  person  greatly  attenuated,  and 
having  an  inguinal  hernia  will  require  a  different  form  of  pad  to 
retain  the  hernia  from  that  of  a  corpulent  person  laboring  under 
a  similar  variety  of  hernia.  The  contour  of  the  parts  differ,  and 
the  floating  adipose  tissue  intervening  demands  a  peculiarly  formed 
pad.  Hence,  the  absurdity  of  a  "radical  cure  truss"  of  fixed  form. 
A  truss  that  will  retain  the  viscera  most  securely,  is  the  only 
reliable  one  tending  to  a  radical  cure  ;  and  even  when  thus  favorably 
conditioned,  of  adults  there  is  less  than  two  per  centum  cured.     Of 


234  Orthop^dia. 

infants,  nearly  every  case  of  ordinary  hernia  is  curable  when  propeily 
retained  by  a  truss. 

The  idea  of  affecting  a  radical  cure  of  hernia  by  pressure  of  con- 
centrated force  upon  the  inguinal  canal,  and  inducing  irritation 
and  consequent  adhesion,  to  the  occlusion  of  the  ring  is  not  pos- 
sible by  any  form  of  truss  pad.  There  may  be  interstitial  deposit 
of  a  substance  analogous  to  that  of  unorganized  false  membrane, 
and  it  may  become  tolerably  permanent ;  yet,  it  is  always  liable  to 
absorption  as  is  the  case  with  all  adventitious  cellular  tissues.  And 
this  is  the  rationale  of  the  radical  cure  of  hernia  in  adults.  The 
seat  of  these  changes  is  the  peritoneum,  forming  the  neck  of  the 
sac,  and  the  portions  of  the  cellular  tissue  which  naturally  occupy 
the  canal  or  orifice  through  which  the  sac  is  formed,  and,  at  a  later 
period,  the  contiguous  fasciae,  or  the  edges  of  the  surrounding  ten- 
dons become  involved,  and,  apparently  a  radical  cure  has  been 
established  —  to  the  delight  of  the  patient  for  the  time  being,  but 
again,  to  their  dismay,  at  the  recurrence  of  their  rupture  in  an 
exaggerated  form, —  the  tissues  being  thinned  and  the  aperture 
greatly  distended  from  the  absorption  that  has  taken  place  in  the 
abnormal  occlusion  of  parts.  The  physiological  condition  tending 
to  the  absorption  of  the  adventitious  formation,  may  be  attributed 
to  the  predisposing  tendency  to  hernia,  and  the  superincumbent 
pressure  of  the  abdominal  viscera  upon  the  unsupported  inguinal 
region.  A  preventive  means  is  here  suggested,  viz. :  that  of  a  sup- 
porting belt  to  the  pendent  portion  of  the  abdomen  to  be  worn  in 
all  cases  where  hernia  has  existed  and  is  supposed  to  be  cured.  This 
of  course  applies  only  to  adults.  The  physiological  tendency  to 
absorption  of  abnormal  formations  of  tissues,  is  witnessed  in  the 
removal  of  the  surplus  osseous  deposits  around  a  fracture  and  the 
solid  deposits  in  the  subcutaneous  cellular  tissues  of  parts,  subjected 
to  undue  pressure,  and  this  applies  equally  well  to  hard  substances 
used  in  truss  pads  when  not  liberally  protected  with  some  elastic 
material ;  yet,  there  is  no  material  so  serviceable  for  a  base  as  a  soft 
wooden  block,  as  it  can  be  most  easily  pared  into  desired  form,  and 
readily  attached  to  the  truss  by  means  of  common  screws  —  afford- 
ing facility  to  the  surgeon  to  remove  and  shape  it  so  as  to  conform 
to  the  hernial  parietes.  In  this  way  the  surgeon  is  enabled  to 
exercise  his  own  skill  in  fitting  his  patient  with  a  truss  —  the  surgi- 
cal instrument-maker  having  supplied  the  spring  and  an  ordiuary 
shaped  soft  wood  block;  having  a  removable  cover,  or  sheath,  wei] 
padded  with  blanketing. 


Hernia,  Procidentia  Uteri,  etc. 


235 


TKUSS   FOR   THE   RELIEF    OF    REDUCIBLE   INGUINAL   AND 
FEMORAL   HERNIA. 

Fiff-92.  represents,  the,  truss,  applied  (1)  —  a  single  truss. 

The  encircling  spring  is  placed  immediately  below 
the  crest  of  the  ilia,  and  secured  by  the  strap  on  a 
stud  riveted  in  the  spnng.  To  this  spring  is  at- 
tached an  un tempered  piece  of  steel,  three  inches 
in  length,  slightly  curved,  and  having  two  holes 
through  it  by  which  to  attach  the  pad  with  com- 
mon, round-headed  screws.  This  piece  of  steel  is 
SO  attached  to  the  mainspring  as  to  admit  of  lateral 
movement  for  adapting  the  pad  to  the  hernial 
aperture.  The  pad  consists  of  a  disc  of  soft  wood 
that  can  be  shaped  as  desired,  and  then  covered 
with  soft  material.  For  inguinal  hernia  a  circular 
disc,  very  slightly  concave  so  as  to  coaptate  to  the  convexity  of  the 
abdomen,  is  required ;  while  for  femoral  hernia  we  need  an  oblong 
convex  surface  to  apply  under  Poupart's  ligament.  Fig.  93  rep- 
resents the  truss  for  femoral  hernia  (2) —  loca- 
tion of  the  spring  below  the  crest  of  the  ilium. 

These  blocks  should  be  covered  with  two  or  three 
thicknesses  of  blanket,  or  other  equally  thick  woolen 
fabric ;  over  that  a  piece  of  soft  leather,  and  on  the 
back  of  the  disc  a  circular  piece  of  sheet  brass  or 
nickel,  having  holes  to  correspond  to  the  holes  in 
the  piece  of  steel  to  which  they  are  attached. 

Fig.  94  represents  a  double  inguinal  truss  having 


Fig.  93. 


Fig.  94:. 


circular  discs,  the  pads  separated 
on  the  one  encircling  spring  about 
four  and  a  half,  or  five  inches, 
for  an  adult.  The  inner  pad  is 
set  about  from  one-eighth  to  one- 
quarter  of  an  inch  lower  than  the  end  pad,  as  the 
end  of  the  spring  dips  from  an  encircling  line 
about  that  much. 

In  this  truss,  the  encircling  spring  crosses  about 
three-fourths  of  the  pendent  portion  of  the  abdo- 
men, and,  when  secured  by  a  strap,  sustains  the 
superincumbent  weight  of  the  abdominal  viscera 
above  the  inguinal  region  —  thus,  in  a  measure, 


236 


Orthop^dia. 


obviating  the  protrusion  by  resisting  the  downward  force.  The 
pads  are  readily  adapted  because  of  the  pad  strips  of  steel,  admit- 
ting of  being  bent,  and  of  a  lateral  movement,  and  the  pad  blocks 
of  being  shaped  to  the  contour  of  the  parts. 

That  infants  are  so  much  more  readily  cured  of  hernia  than 
adults  may  be  attributed  to  the  favorable  conditions  of  growth,  and 
recuperative  tendency  of  the  vital  forces  tending  to  a  constricting 
of  the  no  longer  distended  aperture,  and  in  a  very  limited  period 
compared  to  that  of  an  adult.  Moreover  they  are  subject  to  con- 
trol in  having  the  truss  constantly  applied  day  and  night.  If  this 
is  not  attended  to  carefully,  the  children  are  not  cured.  Children 
cured  of  hernia  but  seldom  have  a  relapse,  because  of  their  predis- 
position being  curable  by  growth,  and  not  existing  as  in  the  case  of 
adults  having  an  undue  pressure  of  the  abdominal  viscera  upon  the 
ino-uinal  region.  Their  ruptures  are  mostly  produced  from  muscular 
contraction  of  the  boundaries  of  the  abdomen,  and  the  open  con- 
dition of  the  rings  in  the  male,  who  is  most  subject  to  inguinal 
hernia,  from  the  recent  descent  of  the  testes  in  which  there  is,  if 
unobstructed,  an  active  tendency  to  diminish  and  strengthen. 

In  exomphalos  or  abdominal  hernia  in  infants,  and  indeed  in 
adults,  an  important  indication  is  met  by  encircling  the  abdomen 
with  a  wide  belt  conforming  to  the  contour  of  the  same  —  thus 
limiting  the  lateral  distending  tendency  of  the  walls  to  the  enlarge- 
ment of  the  aperture. 


Figure  95  represents  the  belt  applied. 
Figure  96  represents  the  belt  complete : 
A  the  pad,  B  the  pad,  tied  with  tapes  in 
the  belt.  The  small  conical  shaped  pad 
as  seen  attached  to  a  thin  metal  shield  of 
several  inches  breadth  and  width,  for 
adults. 

This  appliance  cures  infants  in  a  few  months  and  affords  very 
great  comfort  to  adults. 


Hernia,  Procidentia  Uteri  etc. 


237 


Heraias  in  irregular  regions  of  the  body  can  only  be  supplied 
with  supporting  appliances  by  ingeniously  devised  means. 

Much  relief  is  afforded  in  irreducible  hernia  by  supporting  the 
mass   and    preventing    the   increasing   tendency   to   enlargement, 

Fig.  97. 


as  seen  in  figure  97,  which  represents  a  supporting  apparatus  for 
irreducible  hernia,  and  which  may  be  used  to  much  advantage  in 
scrotal  ailments,  as  it  admits  of  an  adjusting  support  when  pressure 
is  indicated,  as  a  means  of  relief  in  circocele,  and  hernia  humoralis. 
The  cords  attached  to  the  pendent  portion  of  the  sac  are  carried 
backward  and  around  each  thigh  and  brought  forward  in  front  to  be 
passed  through  the  loops  where,  the  ends  being  made  of  tape,  are 
then  tied.  The  straps  passing  through  the  buckles  can  be  gradu- 
ated to  any  desired  degree. 


PEOCIDENTIA  UTERI. 

This  abnormal  position  of  the  uterus  is  a  most  common  ailment, 
and,  like  other  organs  out  of  their  fixed  locality,  is  relievefl  by 
surgico-mechanical  appliances,  for  supporting  the  descending  viscus. 
The  pathological  condition  is  similar  to  that  of  hernia,  advancing 
by  degrees  to  that  of  great  displacement,  involving  the  patient  in 
serious  inconvenience  and  suffering. 

The  primary  cause  of  procidentia  uteri  may  be  considered  as  the 
result  of  a  pathological  condition  of  the  uterine  organs ;  and  not 
that  gravity  has  exceeded  the  resistance  of  vital  energy  in  a  normal 
condition  of  the  person  and  produced  the  ailment.  Various  unfavor- 
able influences  tend  to  this  result;  and,  probably,  the  first  is  aberra- 
tion of  function  tending  to  an  acridity  of  serous  secretion ;  excit- 


238  Ortropmbia. 

ing  an  abnormal  propulsive  effort  of  the  muscles  of  the  pelvis  and 
pendent^portion  of  the  abdomen.  This  is  a  reflex  nervous  influence 
from  a  most  common  condition  of  women  ;  as  more  than  a  majority 
of  them  are  afflicted  with  leucorrhoea,  which,  if  cleanliness  is  not 
observed,  becomes  a  decided  irritant ;  exciting  the  propulsive  effort, 
which  is  expressed  by  women  as  a  "  bearing  down  sensation,"  and,  as  a 
concomitant,  pain  in  the  lumbar  region  and  a  numbness  in  the  thighs. 

The  propulsive  descent  of  the  uterus  is  in  the  direction  of  the 
axis  of  the  pelvis ;  resting  upon  the  perineum  before  its  exit  from 
the  vagina. 

In  a  normal  condition  of  the  uterus  it  is  situated  nearly  in  the 
centre  of  the  pelvis ;  the  distance  of  the  os  uteri  from  the  os  exter- 
num being  about  four  inches.  The  os  uteri  is  situated  at  the 
terminus  of  the  vagina,  projecting  into  it ;  the  outer  surface  being 
covered  by  a  portion  of  the  inner  membrane  of  the  vagina.  In 
the  normal  condition  the  distance  from  the  opening  of  the  os  uteri 
to  where  the  inner  membrane  of  the  vagina  begins  to  be  reflected 
over  it  may  be  nearly  an  inch  ;  the  distance  increasing  in  direct 
ratio  to  the  descent  of  the  uterus  —  producing  an  inversion  of  the 
vagina.  When  tlie  uterus  has  escaped  from  the  os  externum  it 
usually  aggravates  the  suffering  and  increases  the  inconvenience  of 
the  individual.  Previous  to  its  escape,  its  unnatural  pressure  upon 
the  sacro-rectal  region  is  a  cause  of  hemorrhoids,  and  the  pressure 
of  the  fundus  of  the  uterus  upon  the  neck  of  the  bladder  induces  a 
constant  desire  to  micturate  —  at  times,  without  the  ability;  requir- 
ing surgical  assistance.  When  in  this  condition  it  is  a  most  diffi- 
cult matter  to  introduce  a  catheter  into  the  bladder ;  the  point 
of  the  instrument  must  be  be  turned  downward  —  there  being  also 
a  descent  of  the  bladder.  There  is  an  alteration  of  the  relative 
situation  of  the  parts  Avithin  the  pelvis  and  abdomen,  both  in  re- 
gard to  each  other,  and  to  the  containing  parts,  as  the  parietes  of 
the  abdomen  and  the  pelvic  boundary.  The  bladder  descends  with 
the  other  displaced  organs,  requiring,  as  we  have  stated,  in  intro- 
ducing the  catheter  that  the  point  should  be  turned  downward  in 
order  to  have  it  enter  the  viscus  —  an  operation  frequently  de- 
manded under  this  condition  of  the  patient  as  the  descent  of  the 
bladder  contorts  the  urethra  to  such  a  degree  of  imperviousness,  as 
to  prevent  the  passage  of  the  urine.  The  rectum,  instead  of  re- 
maining in  the  curve  of  the  sacrum,  assumes  an  abnormal  position, 
and  with  that  of  a  portion  of  the  abdominal  viscera  fills  the  pelvis. 


Hernia,  Procidentia  Uteri,  etc.  239 

The  descent  of  the  uterus  is  usually  very  gradual,  being  many 
months  gliding  down  to  the  perineum  where  it,  not  unfrequently, 
rests,  as  is  stated  by  Sir  Charles  Mansfield  Clark,  "  as  upon  a  shelf, 
the  violence  of  the  symptoms  abating ;  the  parts  which  suspend 
the  uterus  above,  although  much  lengthened,  being  no  longer  put 
upon  the  stretch.  From  this  circumstance  it  would  appear  that  the 
greater  number  of  the  inconveniences  attending  this  complaint 
depend  less  upon  the  pressure  of  the  uterus  in  the  vagina  than 
upon  the  dragging  of  the  parts  above."  * 

Impairment  of  the  general  health  tends  to  the  descent  of  the 
uterus,  and,  as  a  sequence,  the  mal-positions  attended  with  many 
distresses  and  indescribable  symptoms.  The  most  common  are, 
pain  in  the  side,  lassitude,  failure  in  the  digestive  functions,  and, 
after  a  time,  continued  pain  in  the  lumbar  region,  with  inability  to 
stand  on  the  feet  for  ten  minutes  without  having  forcing  pains  as 
if  to  expel  the  uterus.  The  primary  annoyances  to  the  patient  are 
constipation  and  leucorrhoea ;  i"hen  follows  the  disagreeable  sensa- 
tion of  the  propulsive  eflFort,  that  if  not  relieved  completes  the  pro- 
cidentia uteri. 

The  first  change  of  position  is  deflection  ;  the  fundus  of  the 
uterus  being  forced  downward  while  the  os  remains  in  its  normal 
position  —  hence,  a  curve  in  the  cervix  from  the  pressure  or  pro- 
pulsive muscular  effort  brought  to  bear  upon  the  pelvic  viscera; 
the  result  of  morbid  irritation  of  the  serous  membrane  of  the 
vagina,  and  indicated  in  the  leucorrhceal  discharge.  The  next 
stage  is  retroversion,  or  anteversion,  tending  in  some  cases  to  a 
lateral  deflection.  The  os  tincse  being  enfolded  in  the  vagina,  and 
pressed  against  the  walls  of  the  pelvis,  the  morbid  secretion  destroys 
the  epithelial,  and,  finally,  serous  membrane,  to  that  of  an  ulcerated 
condition  of  the  os  and  cervix  uteri ;  tending  to  neuralgia,  conges- 
tion and  inflammation.  Escharotic  applications  under  these  con- 
ditions of  the  uterus  only  serve  in  some  cases  as  palliative,  and 
are  often  injurious  in  their  tendency,  from  the  fact  of  increasing  the 
irritable  condition  of  the  uterus. 

TREATMENT   OF    PROCIDENTIA    UTERI. 

Admitting  that  which  we  have  stated  in  regard  to  the  pathology 
of  procidentia  uteri,  a  regime  tending  to  the  restoration  of  the 
general  health  of  the  patient,  manual  effort  at  relieving  the  pelvic 

*  "  Observations  upon  Diseases  of  Females  : "  8d  Ed.,  Loud.,  p.  68. 


240  Obthopmdia. 

viscera  by  raising  the  fundus  of  tlie  womb  —  thus  relieving  the  neck 
of  the  bladder  and  rectum  from  compression  —  cleanliness  and 
sedative  means  applied  locally  for  relief  from  the  irritating  leucor- 
rhoeal  discharge,  are  therapeutic  means  of  relief ;  and,  if  successful 
in  affording  permanent  relief  to  the  patient,  establish  the  soundness 
of  the  opinion  as  to  the  pathological  condition  of  the  patient. 

The  treatment  of  the  first  condition  of  the  patient  may  be  left  to 
the  skilful  general  practitioner  —  advising  syringing  of  the  vagina 
twice  or  three  times  a  day  with  water  at  the  temperature  of  the 
body;  thus  neutralizing  and  washing  away  the  acrid  secretions. 
The  second,  being  manual  effort  at  raising  the  fundus  of  the  womb 
to  a  vertical  position,  requires  practical  dexterity  that  may  be 
readily  acquired  from  a  description  of  the  procedure. 

The  erect  position  of  the  patient  is  the  most  favorable  for  arriving 
at  a  correct  diagnosis  of  the  several  mal-positions  of  the  uterus.  In 
the  recumbent  position  the  superincumbent  weight  of  the  abdomi- 
nal viscera  recedes,  and  the  pelvis,  in  a  measure,  relieved  —  so  much 
so,  as  to  deceive  the  practitioner  as  to  the  actual  condition  of  the 
patient ;  moreover,  the  effort  at  restoring  the  uterus  to  its  normal 
position,  and  retaining  it  in  situ,  is  attended  v/ith  much  more  cer- 
tainty when  standing,  than  when  in  the  reclining  position.  The 
effort  at  rising  tends  to  a  return  of  the  abnormal  position  of  the 
uterus  as  we  have  witnessed  in  many  cases. 

The  procedure  is  as  follows :  The  patient  stands  with  the  limbs 
separated,  on  the  left  side,  or  partly  so,  of  the  surgeon  seated  upon 
a  chair.  Having  lubricated  his  fore  and  middle  fingers  with  lard, 
or  oil,  he  inserts  one,  and  if  it  be  possible  without  doing  violence 
to  the  patient,  the  two  fingers  into  the  vagina,  slowly  exploring 
the  internal  condition.  When  the  uterus  is  retroverted,  the  fundus 
may  be  found  resting  in  the  fossa  of  the  sacrum,  and  the  os  tincae 
pressing  the  neck  of  the  bladder  or  the  reverse— the  rectum. 
Then  by  gentle  elevating  pressure,  first  with  both  fingers,  and, 
when  a  slight  yielding  is  obtained,  with  the  fingers  separated,  one 
to  the  position  of  the  os  tincae,  making  an  effort  to  displace  and 
bring  it  down.  By  this  manipulation,  and  by  careful  perseverance, 
the  uterus  will  be  restored  to  its  normal  position. 

Anteversion  of  the  uterus  is  simply  a  reverse  position  to  that 
of  retroversion,  and  much  more  common.  The  os  tincae  in  this 
case  will,  in  many  instances,  be  found  covered  in  a  fold  of  the 
vagina,  requiring  dexterous  manipulation  to  bring  it  forward.     An 


Hernia,  Procidentia  Uteri,  etc.  241 

effort  to  pass  a  finger  behind  it  will  prove  unavailing  before  the 
fundus  is  raised  from  its  position  against  the  pubis  and  neck  of  the 
bladder  —  the  latter  position  being  the  cause  of  the  frequent  incli- 
nation to  urinate  —  while  the  os  tiucae  has  become  ulcerated  from 
being  so  closely  enfolded  in  the  cul-de-sac  of  the  vagina,  and  from 
the  morbid  secretions  thus  retained  about  it. 

The  uterus  being  replaced,  the  patient  should  be  directed  to  get 
on  her  knees  over  a  basin  of  water,  and  wash  the  vagina  thoroughly 
with  the  syringe  and  water,  then  inject  a  small  portion  of  the  fol- 
lowing decoction  into  the  vagina  :  — 

Decoct,  papaver  somnif. Oj 

Zinci  sulph 3  i 

The  ablution  should  be  practiced  morning,  noon  and  night,  end- 
ing each  time  by  using  the  decoction.  This  will  relieve  the  irritable 
condition  of  the  uterus,  and  heal  the  commonly  abraded  condition 
of  the  OS  tincae,  partially  relieving  the  expulsive  effort.  As  an  aux- 
iliary means  of  relief  apply  the  form  of  belt,  as  shown  in  fig.  91,  to 
the  pendent  portion  of  the  abdomen ;  the  modus  operandi  of  which 
we  believe  to  be  an  arrest  by  compression  obliquely  upward,  of  ar- 
resting the  expulsive  muscular  effort  of  that  region ;  as  it  invariably 
afi'ords  relief  to  that  distressing  sensation  and  pain  in  the  back. 
These  displacements  of  the  uterus  in  patients  in  ordinary  health, 
but  seldom,  if  ever,  fail  to  be  relieved  by  the  treatment  here 
described.  A  repetition  of  the  manipulation  at  least  once  a  week 
for  three  or  four  weeks,  will  be  required  in  cases  of  long  standing, 
to  insure  success  from  this  treatment.  There  is,  in  some  cases,  a 
lateral  tendency  of  the  uterus  in  its  descent;  but  it  requires  no 
special  treatment  from  that  of  the  conditions  described. 

The  uterus,  in  its  descent,  often  carries  before  it  the  bladder  ;  pro- 
ducing prolapsus  vesicce.  This  is  one  of  the  conditions  of  the  re- 
troverted  viscera  that  is  more  perplexing  to  the  practitioner  than  all 
that  class  of  ailments.  The  successful  treatment  of  procidentia  or 
prolapsus  uteri,  contributes  largely  to  its  relief,  and  then  the  replac- 
ing of  the  bladder  should  follow.  The  patient  should  be  made  to 
recline  on  her  back  with  her  hips  elevated  for  one  or  two  hours, 
.twice  or  three  times  a  day,  and  this  rest  and  position  should  be  fol- 
lowed by  an  injection  into  the  vagina  of  a  solution  of  a  drachm 
and  a  half  of  zinci  sulph.  to  a  quart  of  water. 


242 


Orthopjebia. 


Fig.  99. 


This    greatly   allays   the   irritation    that  Fig.m. 

tends  to  the  expulsive  effort,  as  also  the  dis- 
tention of  the  vagina  and  the  concomitants 
of  the  ailment.  A  decided  auxiliary  to  tho 
treatment  is  the  abdominal  support  belt  and 
perineal  eleva-tor  as  applied.    Fig.  98. 

A,  the  front  of  the  belt  having  two  but- 
tons for  attaching  the  cross-straps  that  are 
intended  to  be  passed  between  the  limbs. 
B,  the  back  of  the  belt  having  the  cross- 
straps  c,  attached,  and  the  perineal  elevator 
sheathed  upon  them.     See  Fig.  99. 

Fig.  100.  A  represents  the  cross-strap,  and 
B  the  elevator,  of  tri- 
angular form  having 
at  the  base,  loops  of 
about  two  inches 
in  lengtli  through 
which  the  cross- 
straps  pass ;  a  ver- 
tical, transverse  sec- 
tion (B)  giving  the  form  —  the  apex  to  be  applied  to  the  perin- 
eum. The  elevator  is  from  an  inch  and  a  half  to  two  inches 
in  height,  presenting  an  external  vertical  support 
to  the  uterus  by  elevating  the  perineum  when  firmly 
applied,  which  we  believe  to  bo  more  effectual  in 
relieving  procidentia  or  prolapsus  uteri  than  any 
pessaries  at  present  in  use.  Pessaries  tend  to  excite 
leucorrhoeal  discharges,  and  relaxation  of  the  vagina, 
and,  in  many  cases,  the  patient's  health  is  greatly  im- 
paired by  their  use;  whilst,  by  the  elevation  of  the 
perineum  to  a  sustaining  of  the  uterus,  the  lateral  liga- 
ments of  that  organ  are  relieved  from  extension,  and 
the  vagina  restored  to  a  normal  condition. 


Fig.  100. 


Hernia,  Procidentia  Uteri,  etc. 


243 


ECTROPION  VESICiE. 
The  most  common  designation  of  this  malformation  is  that  of 
extroversion  of  the  bladder  ;  as  the  aaterior  portion  of  this  viscus 
is  deficient,  and  the  parietes  of  the  abdomen  that  should  form  its 
normal  covering  are  wanting,  so  that  the  posterior  and  lower  portion 
protrudes  under  the  pressure  of  the  abdominal  viscera,  presenting  a 
secreting  tumor  covered  with  a  mucous  membrane  in  which  the 
orifices  of  the  ureters  can  be  seen  —  the  urine  exuding  from  them. 
The  umbilicus  is  not  distinctly  marked,  but  usually  indented  by  an 
elongated  indentation.  The  linea  alba  is  bifurcated  at  the  upper 
angle  of  the  umbilical  cincture,  and  continued  on  either  side  down 
to  the  OS  pubis,  so  as  to  form  a  triangle  in  which  the  extroverted 
bladder  lies.  The  pubic  bones  are  not  united  by  a  symphysis  but 
joined  to  each  other  by  ligament.  The  penis  is  small ;  the  corpus 
spongiosum  is  wanting  ;  and  only  a  remnant  of  the  urethra  remains, 
presenting  a  mere  groove  lined  with  mucous  membrane  on  the  dor- 
sum of  the  rudimentary  penis  leading  to  the  vesical  tumor.  The 
glans  penis  is  full  and  large,  and  the  prepuce  usually  of  full  size, 
but  cleft  above  as  though  the  operation  for  phymosis  had  been  per- 
formed. The  testicles  are  usually  found  in  a  contracted  scrotum. 
In  either  groin  loose  folds  of  skin  contain  hernial  protrusions.    This 

applies  to  the  male.  Female  sub- 
jects have  been  found  thus  con- 
ditioned ;  the  exposed  mucous 
membrane  extending  to  the  va- 
gina. 

This  deformity  is  attended  with 
much  suffering ;  the  exposed, 
tender  surface  of  the  protruding 
bladder  covered  with  pendulous 
papillae  bleeds  freely  when,  almost 
unavoidably,  chafed  by  the  cloth- 
ing that  is  saturated  with  urine, 
while  there  is  emitted  a  con- 
stant stench,  making  it  altogether 
a  hopeless,  disgusting  infirmity. 
For  the  relief  of  this  sad  ail- 

1.  The  secreting  surface  of  the  bladder. 

2.  The  rudimentary  penis.  mcut,  modem  surgical  Operations 

3.  The  distended  scrotum,  from  nor-    ^^^ve  been  unsuccessfully  attempt- 
mal  distension. 


Fig.  101. 


244  ORTHOPJEnTA. 

ed  by  the  most  eminent  in  the  profession.  Plastic  operations 
have  been  performed,  and  failed  in  limiting  the  extent  of  the 
secretory  surface  to  that  of  a  controllable  drain,  by  diverting  the 
course  of  the  urine  into  the  rectum.  Such  procedures  have  proved 
most  hazardous  to  life,  with  little  promise  of  success  in  the  future. 
A  well-fitting  female  urinal  serves  to  catch  the  urine  and  retain 
it,  and  also  relieves  the  person  from  the  intolerable  stench,  that 
is  so  oflFensive,  arising  from  the  saturated  clothes,  under  ordinary 
circumstances.  The  annexed  engraving  represents  the  condition 
of  the  person.  The  secreting  surface  of  the  bladder,  as  seen  above 
the  rudimentary  cleft  penis,  and  the  distended  scrotum  beneath 
and  posterior  to  the  glans  penis. 


RELAXED  ABDOMEN, 

Relaxed  abdomen  is  an  ailment  that  subjects  both  male  and 
female  to  much  inconvenience  and  suffering,  tending  to  an  increase 
of  obesity  of  the  abdomen  far  exceeding  the  tendency  to  that  con- 
dition of  the  limbs.  A  belt,  as  described  above  for  abdominal 
hernia  (omitting  the  hernial  pads)  will,  if  applied,  arrest  the  tend- 
ency to  pendent  abdomen,  and  afford  much  comfort.  In  women 
the  predisposition  to  relaxation  of  the  abdominal  visceral  supports 
tends  to  pressure  upon  the  pelvic  supports,  inducing  their  derange- 
ments, such  as  procidentia  uteri  and  vesicae ;  which  ailments  are 
relieved  by  the  belt. 

The  patient,  under  use  of  the  belt,  seldom  fails  to  find  relief  from 
the  pendent  abdomen  and  local  derangement,  and,  in  many  in- 
stances, a  perfect  cure,  if  their  health  is  also  improved  by  a  judi- 
cious regime.  Sedative  tonics,  such  as  ext.  valer.  gr.  1,  ferri 
sulph.  gr.  i ;  taken  three  times  a-day,  afford  much  relief  if  laboring 
under  an  irritable  nervous  condition.  In  cases  of  failure  in  the 
digestive  functions  tending  to  acid  eructations,  bismuthi  subni- 
tratis  grs.  5,  quinige  sulph.  gr.  ^ ;  taken  morning,  noon  and  night, 
is  most  salutary  in  its  curative  tendency. 

Sea  sickness  is  greatly  mitigated  by  wearing  this  abdominal  belt, 
as  it  arrests  the  tendency  to  relaxation  of  the  abdominal  walls,  and 
arrests  visceral  agitation  from  the  motion  of  the  vessel. 

Prolapsus  ani  and  hemorrlwids  may  be  considered  concomitants 


Hernia,  Procidentia  Uteri,  etc.  245 

of  relaxed  abdomen.  The  abdominal  belt  with  the  perineal  sup- 
port affords  very  efficient  means  of  relief  as  an  auxiliary  to  other 
treatment — affording  pressure  to  the  hypogastric  region  that  in- 
variably gives  relief  to  the  distressing  propulsive  efforts  attending 
these  ailments. 

Prolapsus  ani  most  commonly  occurs  in  children  when  en- 
feebled and  suffering  from  irritation  of  the  digestive  or  urinary 
organs.  In  delicate  adults,  there  is  also  a  natural  tendency  to  this 
ailment.  A  slight  protrusion  of  the  mucous  membrane  takes  place 
during  defecations,  and  is  increased  by  any  constitutional  tendency 
to  atony  of  the  muscular  system. 

The  most  common  causes,  however,  are  irritation  of  the  intes- 
tinal mucous  membrane  from  morbid  secretions  in  an  abnormal 
functional  condition,  as  habitual  constipation  often  occurring  in 
persons  of  a  relaxed  habit  of  body,  a  want  of  power  in  the  rectum 
to  expel  its  contents,  requiring  a  constant  straining  at  stool,  and 
diseases  of  the  urinary  organs,  as  that  of  stricture  or  stone  requiring 
effort  to  micturate.  Mr.  John  E.  Erich  sen  states  :  "  In  other  cases, 
and  indeed  most  usually,  the  prolapsus  is  associated  with  piles,  the 
weight  and  dragging  of  the  hemorrhoid  drawing  down  the  mucous 
membrane  of  it. 

Diagnosis :  The  prolapsus,  as  before  stated,  consists  in  the  pro- 
trusion of  the  mucous  membrane  of  a  red,  purplish  color,  having  a 
turgid,  lobulated  appearance  varying  in  size.  The  protruded  mucous 
membrane  is  continuous  with  that  investing  the  sphincter,  and  this 
constitutes  the  mark  of  distinction  between  the  ordinary  prolapsus 
and  the  invagination  that  occasionally  presents.  In  this  condition 
a  deep,  distinct  sulcus  will  be  observed  between  the  protrusion  ana 
the  margin  of  the  sphincter.  In  chronic  cases  of  prolapsus  ani  the 
anal  aperture  is  often  permanently  relaxed  and  widened  within; 
externally,  folds  of  skin  are  apparent,  from  relaxation  radiating 
from  the  anal  centre,  having  a  bluish,  soft,  pendulous  appearance 
and  attended  with  intolerable  itching.  The  protrusion,  at  first,. 
occurs  only  after  defecation,  and  readily  retracts,  or  is  reduced 
by  application  of  steady  pressure  upon  it.  Subsequently,  if  not 
permanently  relieved,  it  will  protrude  after  riding,  walking,  or 
standing,  and  returned  with  much  pain  and  difficulty. 

Treatment. — In  children,  the  cleansing  and  bathing  the  protrusion 
with  moderately  cold  water,  and  if  retraction  has  not  ensued  efforts 
must  be  made  at  reduction.     To  the  accomplishing  of  this,  a  piece 


246  Orthopjedia. 

of  worn  linen  folded  one  or  two  thicknesses,  smeared  on  one  side 
with  simple  cerate,  should  be  applied  to  the  prolapsed  bowel ;  then 
find  the  anal  orifice  with  the  finger,  passing  it  well  into  the  bowel ; 
press  the  protruding  parts  slowly  into  the  rectum,  and  after  a  few 
moments  withdraw  the  linen.  Prof.  Vogel,  in  his  most  excellent 
treatise  on  diseases  of  children,  translated  from  the  German  by  Prof 
H.  Eaphael,  M.  D.,  states  that  "  it  is  very  useful  to  slide  a  small 
round  piece  of  ice  into  the  prolapsus  before  the  reduction  is  under- 
taken, and  then  to  reposite  the  protruded  bowel  with  the  ice." 
Astringent  injections  are  reliable  means  of  cure  ;  sulphate  of  iron 
one  to  five  grains  in  an  ounce  of  water,  injected  merely  within  the 
retaining  power  of  the  sphincter,  and  in  such  small  quantities  as  to 
be  retained ;  careful  attention  to  the  maintaining  of  a  normal  con- 
dition of  the  bowels ;  a  nutritious  diet  enforced ;  and  a  pledget  of 
lint  made  wet  with  cold  water  and  applied  to  the  anal  region,  and 
sustained  by  the  abdominal  and  perineal  support  obtains  usually  a 
cure  in  children. 

In  adults  if  not  accompanied  with  hemorrhoids,  the  above  treat- 
ment is  quite  efficient  to  their  relief  In  cases  where  hemorrhoids 
exist,  the  removal  of  the  piles  by  ligature  cures  the  prolapsus. 

When  prolapsus  fails  to  be  relieved  by  palliative  treatment  a  por- 
tion of  the  protruded  mucous  membrane  must  be  removed,,  and  for 
the  accomplishment  of  which  we  prefer  the  ligature,  thus  avoiding 
the  tendency  to  exhausting  hemorrhage.  In  case  of  strangulation 
of  the  parts  protruded,  strenuous  efforts  should  be  made  for  its  reduc- 
tion, and  if  not  possible  free  incision  of  the  sphincter  may  be  made. 
If  not  reduced  it  will  slough  off,  and  thus  tend  to  a  permanent  cure. 

Hemorrhoids. — In  this  ailment  much  relief  is  afforded  by  having 
the  parts  regularly  sponged  with  cold  water  and  cloths  wet  in  it  and 
applied  to  the  parts ;  or  a  solution  of  Barbadoes  tar  which  is  a  most 
effectual  remedy ;  and  in  cases  of  internal  piles,  injections  of  it  are 
usually  very  efficaciou  s.  The  following  electuary  affords  very  decided 
relief  in  cases  thus  conditioned : 

Pulv.  nucis  moschatae         3  ij 

Sulph.  sub. 

Conserva  rosse,     aa  31 

Pt.  electuary. 


Hernia,  Procidentia  Uteri,  etc.  247 

A  drachm  of  this  taken  night  and  morning,  usually  gives  relief 
from  the  tenesmus  and  distressing  pain. 

In  the  treatment  of  hemorrhoids,  it  must  be  considered  that  the 
ailment  is  the  result  of  some  remote  visceral  disarrangement,  requir- 
ing careful  observation  and  a  corrected  regime,  otherwise  treatment 
will  fail  to  afford  permanent  relief ;  as  in  all  this  class  of  ailments, 
the  result  of  an  enfeebled  condition  of  the  system,  a  well  devisea 
constitutional  treatment  is  imperative  even  to  the  relief  of  the 
patient,  then  local  palliative  appliances  will  not  disappoint  the  prac- 
titioner's expectations  in  treatment. 

Constipation  of  the  bov^els  is  the  most  common  cause  of  hemor- 
rhoids. Many  persons  subject  to  this  painful  disease  keep  the 
following  preparation:  Sulphur,  one  ounce;  treacle,  eight  ounces; 
and,  when  the  premonitory  indications  present,  take  an  ounce  on 
retiring  at  night,  and  repeat  this  until  relief  is  afforded.  By  this 
precautionary  effort  much  suffering  is  obviated. 

Alarming  hemorrhage  occurs  in  protracted  cases,  and  requires 
prompt  treatment,  especially  in  cases  of  pregnant  women,  who  are 
most  subject  to  this  ailment,  and  negligent  of  their  condition.  The 
most  reliable  means  of  relief  is  the  insertion  of  ice  in  the  rectum  ; 
but  here  presents  a  most  important  consideration,  as  the  remedy 
may  produce  abortion.  In  such  cases,  the  per  chloride  of  iron 
cautiously  applied  by  an  experienced  medical  practitioner  serves  a 
good  purpose.  A  "  T  "  bandage,  having  a  steel  belt  above  the  hips 
and  a  conical  shaped  cork  of  about  an  inch  in  height  on  the 
perineal  belt,  serves  an  admirable  purpose,  when  worn  by  persons 
afflicted  with  chronic  hemorrhoids. 


CHAPTER  X. 

VAEICOSE  VEINS— BURSiE— GANGLION. 

Persons  specially  amenable  to  Varicose  Veins. — Differing  indications  of  ail- 
ment.— Diagnosis  given  in  Holmes's  "  System  of  Surgery." — The  oedematous 
leg  and  varicose  ulcer. — Women  more  liable  than  men  to  varicose  veins. — The 
affection  described. — Congestion  may  exist. — John  Kent  Spencer  upon  the 
pathology  and  treatment  of  ulcers  and  cutaneous  diseases  of  the  lower  limbs. 
Varicose  ulcers. — Description  of  the  Syphilitic  ulcer. — Treatment  of  ulcers  of 
the  leg. — Mechanical  appliances  used. — System  of  Measurement. — Beneficial 
effect  of  the  laced  stocking. — BtJRS^. — Bursae  mucosae  and  bursse  synoviae. — 
Distinctive  symptoms  described. — Mr.  Paget's  opinions  regarding  them. — The 
"  Housemaid's  Knee." — Unfavorable  changes  in  pathological  order. — Treatment 
of  Bursae. — Erichsenon  Pathology  of  Chronic  Enlargements  of  Bursas. — Gang- 
lion ;  Diseases  of  Sheaths  of  Tendons. — Diagnosis  of  Ganglion. — Treatment. 


VARICOSE   VEINS. 

The  pathological  impairments,  tending  to  a  varicose  condition  of 
the  veins  of  the  lower  extremities,  have  not,  as  yet,  been  satisfactorily 
comprehended.  Various  opinions  have  been  advanced,  but  not  ad- 
mitted as  the  actual  cause  of  this  most  common  ailment,  being 
only  one-third  less  in  frequency  than  abdominal  hernia,  with  which 
every  tenth  person  is  afflicted ;  and  like  it,  too,  for  relief,  surgico- 
mechanical  appliances  are  indicated,  which  but  seldom  afford  per- 
manent relief. 

Persons  suffering  from  varicose  veins  are  those  whose  vocation 
requires  the  erect  passive  position  of  the  body ;  as  that  of  many 
trades,  book-keepers,  cardrivers,  washerwomen,  cooks,  and  all  kinds 
of  labor  demanding  a  standing  position  for  great  lengths  of  time. 
These  all  tend  to  induce  the  ailment,  and,  if  not  relieved,  in  most 
cases,  the  limbs  become  painful,  and  swollen ;  then  follow  erythema, 
inflammation,  and,  finally,  extensive  ulceration. 

Necessity  compels  a  vast  number  of  the  indigent  to  labor  for 
their  subsistence,  even  when  afflicted  with  varices  from  the  unfavor- 


Varicose  Veins,  etc.  249 

able  employment;  and  from,  even,  careful  observation,  it  is  not 
possible  to  decide  whether  there  is  a  constitutional  predisposition 
to  the  ailment,  or  that  the  pathological  condition  is  the  sequence  of 
the  unfavorable  influence  of  position  even  upon  all  constitutions. 
That  some  yield  more  readily  than  others  to  the  unfavorable  influ- 
ence, and  suffer  more  from  its  encroachment  must  be  admitted,  but 
this  is  from  a  normal  condition  of  the  individual ;  being,  compara- 
tively, deficient  in  physical  resistance  to  all  unfavorable  influences. 
Persons  afflicted  with  varicose  veins,  differ  greatly  in  the  indica- 
tions and  appearances  of  the  limbs  affected.  The  first  and  most 
common  indication  peculiar  to  the  ailment  in  all  those  affected 
with  it  are  deep,  aching  pains  in  the  limb,  with  a  sense  of  weight, 
fullness,  and  fatigue.  These  are  the  first  indications  of  the  con- 
gested condition  of  the  peripheral  veins,  and  from  a  slight  bruise 
an  effusion  of  blood  in  the  cellular  tissue  ensues,  leaving  a  dark 
spot;  or,  a  very  slight  wound  will  bleed  most  profusely,  and  tend  to 
ulcerate.  This  condition  is  common  to  all  classes  of  persons  sub- 
ject to  the  ailment.  However,  these  initiatory  symptoms  are  the 
only  unfavorable  indications  that  are  apparent  to  observation,  yet 
the  patients  are  subject  to  the  ulcerative  sequence.  The  impeded 
circulation  is  denoted  by  these  symptoms,  and  limited  to  the  deep 
seated  consequently  constricted  veins,  which  receive  all  the  blood 
from  the  distended  peripheral  veins  —  there  being  no  large  conduits 
immediately  in  the  dermoid  tissue,  which  becomes  vitally  impaired 
from  congestion.  In  this  class  of  patients  the  diagnosis  is  very 
obscure  and  fails  of  proper  treatment,  being  confounded  with  other 
more  serious  ailments.  Of  this  peculiarity  in  the  ailment,  writers 
have  not  made  mention  although  a  quite  common  condition  of 
patients.  In  Holmes'  "  System  of  Sui"gery,"  a  very  concise  descrip- 
tion of  the  more  conspicuous  conditions  of  the  ailment  is  given.* 
After  a  time,  which  varies  with  the  idiosyncrasy  and  occupation  of 
the  patients,  small,  soft,  blue  tumors  are  seen  at  different  points  in 
the  leg ;  most  of  them  will  disappear  on  pressure,  but  will  return 
when  the  pressure  is  removed,  or  when  the  patient  stands.  Each 
little  tumor  is  caused  by  a  superficial  vein  dilating  to  a  point  at 
which  it  is  joined  by  an  intra-muscular  branch.  Around  many  of 
the  tumors  a  number  of  minute  vessels  are  clustered,  of  a  dark  pur- 
ple color ;  these  being  the  small  superficial  veins  which  enter  the 

"  Vol.  Ill,  p.  314. 


250  Orthofjebta. 

large  superficial  dilating  vein,  and  in  which  the  blood  is  retarded 
in  its  passage.  An  increasing  length  of  vein  becomes  gradually 
involved,  and  a  number  of  irregular,  knotty,  convoluted  tumors  are 
developed,  grouping  themselves  around  the  points  at  which  the 
dilatation  first  began.  The  external  and  internal  saphena  veins  are 
those  principally  affected,  but  long  tracks  of  tortuous  veins  may 
extend  up  the  leg  and  thigh.  Dangerous  and  even  fatal  hemorrhage 
may  ensue  from  the  bursting  of  a  varix  through  the  skin.  The 
vessels  may  become  filled  with  clots,  and  permanently  obstructed. 
Ulceration  and  disease  of  the  skin  are  some  of  the  most'  common 
pathological  sequels  in  cases  of  long  standing. 

There  are  but  few  more  painful  lesions  of  tissue,  or  disenabling 
ailments  from  labor  than  that  of  the  oedematous  leg  and  varicose 
ulcer  —  the  sequence  of  varicose  veins.  Persons  of  feeble  constitu- 
tions thus  affected  mostly  labor  u>nder  superficial  indolent  ulcera- 
tion, whilst  those  of  a  more  robust  condition  suffer  greatly  from  the 
irritable  ulcer.  The  young  rarely  suffer  from  varicose  veins.  This 
would  indicate  that  certain  occupations  eligible  only  to  adults 
tended  to  this  ailment.  Women  are  much  more  liable  to  varicose 
veins  than  men,  and  when  ulceration  ensues,  their  cases  become 
most  intractable.  The  locality  of  the  varicose  ulcers  is  most  com- 
monly on  the  inner  and  lower  third  of  the  leg,  the  location  present- 
ing indications  for  a  considerable  time  before  the  ulceration  ensues; 
as  that  of  erythema  and  discoloration.  This  discoloration  is  attrib- 
uted to  a  neurose  derangement  of  the  vasa-motor  nerves,  and  to  the 
partial  arrest  of  nutrition ;  denoting  not  only  impeded  circulation, 
but  waste  or  diminution  of  cuticular  tissue,  which  is  often  covered 
with  dry  scales  that,  Avhen  removed,  expose  a  secreting  surface  that 
tends  to  ulceration,  having  a  border  of  hardened  connective  tissue. 
This  ulceratioa  appears  to  be  an  entire  destruction  of  the  dermoid 
tissue,  often  extending,  irregularly,  half  way  around  the  leg. 

The  legs  are  greatly  exposed  to  injuries,  more  often,  in  fact,  than 
the  other  parts  of  the  body,  and  upper  extremities.  G-reater  stress  is, 
also,  brought  to  bear  on  their  vital  forces  from  unfavorable  occupa- 
tions, as  would  naturally  necessitate  long  continued  standing  in  a 
comparatively  quiescent  condition.  This  leads  to  an  impairment  of 
functional  nutrition  of  the  dermal,  sub-dermal  and  connective 
tissues.  In  the  incipiency  of  a  more  serious  lesion  we  have  an 
erythematous  irritation  attended  with  a  most  intolerable  itching, 
which,  from  an  abrasion  of  the  surface,  secretes  a  morbidly  acrid 


Varicose  Veins,  etc.  251 

excretion,  increasing  the  local  irritation  to  the  degree  of  a  circum- 
scribed ulcer,  and  a  general  oedematoiis  condition  of  the  leg  below 
the  knee,  and  which  tends  to  impede  the  general  venous  circulation 
and  increase  the  congestion  and  swelling. 

This  condition  of  the  limb  often  exists  independently  of  a 
previous  varicose  condition  of  the  veins,  and  it,  therefore,  does  not 
follow  that  varicose  veins  are  the  invariable  indication  of  simple 
ulceration  of  the  legs. 

In  the  normal  condition  of  the  legs  it  must  be  admitted  that  the 
physical  law  of  gravity  is  stronger  than  the  dynamical  influence 
governing  the  circulation  in  the  ascending  venous  return  of  blood 
from  the  lower  extremities ;  which  is  subject  to  a  limit  of  force  and 
is  an  actual  cause  of  varicose  veins —  more  especially  in  persons  of 
feeble  muscular  energy,  in  whom  ulceration  of  the  limbs  is  not 
alwa5''s  a  result  of  that  abnormal  condition  of  the  veins,  even  when 
greatly  distended. 

Congestion  of  all  of  the  soft  tissues  may  exist,  and  from  a  similar 
cause  to  that  producing  varicose  veins;  but  a  varicose  condition  has 
not  resulted  because  of  a  more  numerous  division  of  the  superficial 
veins  of  small  calibre  —  a  peculiar  condition  of  the  limbs  in  some 
persons.  In  such  persons  numerous  patches  of  discoloration  will 
present,  and,  on  examination,  will  apparently  consist  of  capillary 
veins  and  exudation  of  venous  blood  under  the  cuticle. 

From  slight  injury,  persons  thus  conditioned  are  subject  to 
ulcers  of  the  leg,  and  no  varicose  veins  presenting,  a  doubt  may  be 
entertained  as  to  the  simple  character  of  the  ulcer  which  is  identi- 
cal, in  a  pathological  point  of  view,  with  that  of  the  varicose  ulcer, 
and  subject  to  relief  by  similar  treatment.  Mr.  John  Kent  Spencer, 
in  his  manual  upon  the  pathology  and  treatment  of  ulcers  and 
f.utaneous  diseases  of  the  lower  limbs,  states  that  varicose  and 
obstructed  veins  are  the  remote  causes  of  nearly  every  form  of  non- 
traumatic ulcer  in  the  lower  extremities,  and,  that  it  may  be  said 
to  be  the  most  common  cause  of  indolent  ulceration  of  the  limbs 
having  resulted  from  accidental  injury. 

VARICOSE    ULCER. 

The  varicose  ulcer  is  liable  to  be  confounded  with  the  syphilitic 
alcer,  of  which  last  we  will  here  give  a  description:  "Syphilitic 
ulcers  may  result  from  pustules,  tubercles,  boils,  or  may  begin  as 
tertiary  sores;    they  frequently  occur  where  the  integuments  are 


262  Orteop.^bia. 

thin,  or  where  they  are  moistened  by  the  natural  secretions  of  the 
parts.  They  are  circular,  with  elevated  edges ;  tend  to  spread  in 
circles,  with  a  foul  greyish  surface ;  often  creeping  along  slowly, 
and  destroying  deeply  the  parts  they  aifect ;  leaving  cicatrices  of  a 
bluish  or  brown  color,  thin  and  smooth,  which  are  apt  to  break 
open  again  on  the  application  of  any  slight  irritation."  * 

It  is  of  much  importance  to  determine  the  true  character  of  the 
ulcers  of  the  leg.  The  varicose  ulcer  is  curable  by  simple  local 
treatment,  the  patient  being  otherwise  in  good  health,  or,  if  feeble, 
rest  and  liberal  diet  is  sufficient.  But  if  the  ulcer  is  of  syphilitic 
origin,  a  general  constitutional  medication  will  be  required  to  insure 
even  tolerable  success. 

The  varicose  ulcer  is  preceded  by  a  varicose  condition  of  the  veins, 
and,  as  a  sequence,  oedema,  erythema,  a  large  patch  of  discoloration, 
and  lastly,  ulceration ;  usually  by  dissolution  of  the  superficial 
integument,  leaving  an  irregular  formed  ulcer  and  limited  to  the 
inner,  lower  third  of  the  leg  —  inmost  cases.  There  are  excep- 
tional cases  when  the  ulceration  exists  about  the  malleola. 

Mr.  Maunder  states  in  the  London  Hospital  Reports,  vol.  ii,  p.. 
129,  that  all  those  cases  which  are  situated  above  the  middle  of  the 
leg  are  syphilitic  in  their  origin,  and  are  mostly  multiple,  also ; 
while  the  varicose  ulcers  are  found  below  the  middle  of  the  leg,  and 
are  usually  solitary. 

TEEATMEISTT. 

In  the  first  stage  of  the  ailment  it  is  necessary  to  consider  the 
indications  that  present:  Dilatation  of  the  dermal  veins,  inefiiciency 
of  the  valves  to  prevent  regurgitation,  oedema  of  the  connective  tissue, 
and  passive  congestion  of  the  capillaries.  These  are  all  indications, 
to  be  relieved  by  moderated  compression,  which  will  assist  the  valves 
in  sustaining  the  column  of  blood.  It  will  also  restore  the  lymphatic 
and  superficial  blood  vessels  to  their  normal  physiological  state. 

This  stage  of  the  ailment  having  been  relieved  arrests  the  progress 
to  the  ensuing  stage,  and  is  of  the  utmost  importance  to  the  patient. 
The  most  reliable  means  for  this  purpose  is  the  non-elastic  laced 
stocking. 

*  Erlchsen's  Surgery,  4th  edition,  p.  539. 


Varicose  Veins,  etc. 


253 


Fi0.1O2.  A,  B,  C,  D. 


T'igs.  102  represent  the  appliances 
used  for  compression.  A,  a  laced 
stocking  for  tlie  leg ;  the  dotted  lines 
representing  whalebones  encased  to 
prevent  the  stocking  from  wrinkling. 
B,  a  knee  bandage.  C,  an  ankle 
bandage.  D,  leather  stiffen ings  as  a 
support  under  the  malleoli ;  being 
thin  sole  leather,  thinned  on  the  edges 
and  secured  by  a  covering  of  soft 
leather,  the  leather  being  made  wet, 
becomes  pliable,  and  when  the  ban- 
dage is  laced  upon  the  ankle  co-aptates 
to  the  form  and  gives  an  admirable 
support  to  a  weak  ankle. 
Figs.  103  and  104  represent  the  pro- 
per parts  for  measuring,  in  order  to 
suitably  fitting  bandage.     For  a  knee  bandage   the  cir- 

'Cumference  should  be  taken  at  A,  B  and  C ;  and  the  length  from 

A     to   D.      For    an 


obtain   a 


Figs.im.  104. 


ankle  bandage  or  sock,  the  circumference 
at  A,  B,  D  and  E;  and  the  length 
from  A  to  C.  The  second  figure  has 
the  points  of  measurement  for  a  laced 
stocking — circumferences  at  A,  B, 
C,  E  and  F;  length  from  A  to  D. 
These  figures  delineating  the  meas- 
urements also  represent  the  wire 
spring  cloth  stocking  and  knee-cap  > 
the  only  admissible  elastic  material 
that  should  be  used  for  such  pur- 
poses, as  it  is  not  affected  by  tem- 
perature as  is  the  case  with  India 
rubber  which  is  not  only  rendered 
soluble  by  perspiration,  but  becomes  a  decided  irritant;  often  excit- 
ing erysipelas  when  worn  in  warm  rooms  or  during  the  heat  of  sum- 
mer. Elasticity  is  not  an  essential  quality  in  the  construction  of 
these  bandages,  and  is  objectionable  because  of  the  unavoidable 
thickness  of  the  elastic  material  which  tends  to  increase  and  main- 
tain the  existing  increased  temperature  of  the  diseased  limb.  Light 
woven  fabrics  meet  the  indications  more  fully  as,  when  made  to  fit. 


D   ? 


dE 


254  OrTHOPjEBIA. 

and  laced  moderately  tight,  its  equable  pressure  facilitates  the  return 
of  the  blood  in  the  superficial  veins,  and  when  laced  to  a  suitable 
degree,  being  porous,  admits  of  exhalations  passing  through,  greatly 
to  the  comfort  and  tending  to  the  cure  of  the  patient.  The  laced 
stocking,  knee  and  ankle  bandage,  as  represented  in  figure  96,  are 
most  simple  in  construction.  By  doubling  ordinary  twilled  cotton 
cloth,  and  marking  out  with  a  pencil  the  forms  as  represented,  obtain- 
ing the  correct  dimensions  from  proper  measurement  —  taking  one 
half  the  circumference  for  the  measure,  as  the  material  is  doubled 
they  will,  by  allowing  half  an  inch  for  seams,  fit  the  limb  perfectly. 
For  the  lacing,  as  seen,  one  side  is  to  be  cut  and  faced,  all  the  edges 
to  be  bound  with  tape.  Any  tailor  or  seamstress  can  readily  make 
these  bandages,  and  thus  contribute  to  the  relief  of  numerous  suf- 
ferers from  the  ailments  of  varicose  veins,  weak  knees  and  ankles. 

In  the  treatment  of  varicose  ulcers,  the  laced  stocking  tends  greatly 
to  success.  If  inflammation  and  pain  is  excessive,  and  the  patient's- 
condition  in  regard  to  their  subsistence  will  admit  of  their  being 
placed  at  rest,  it  is  advisable ;  yet  relief  can  be  given  the  patient  even 
while  at  labor,  by  the  application  of  the  laced  stocking,  and -the  sub- 
joined treatment.  The  following  lotion  and  dressing  should  be' 
applied  at  night ;  plumbi  acet.  et  zinci.  sulph.  aa  3i;  aqua  font- 
oj.;  vin.  opii.  3  ss.  M.  ft.  sol.  Several  thicknesses  of  worn  linen 
or  cotton  fabric  should  be  wet  with  this  lotion,  or  ordinary  lime 
water,  and  applied  to  the  ulcer.  Over  this  and  the  exposed  inflamed 
parts  of  the  leg  a  towel,  folded  and  made  wet  with  water  at  a  tem- 
perature not  under  60°  Fahr.,  should  be  applied.  In  the  morning 
the  ulcer  should  be  dressed  with  fresh  mutton  tallow,  and  some  lint 
or  folded  cloth  to  absorb  the  secretion — covered  with  oil-cloth — and! 
the  laced  stocking  laced  firmly  on  the  leg.  If  the  pain  is  not 
relieved  in  a  few  days  the  ulcer  should  be  penciled  with  a  solutioiu 
of  nitrate  of  silver,  four  grains  to  the  ounce  of  distilled  watei\  A 
few  applications  of  this  solution  usually  afl'ords  relief.  The  general' 
health  of  the  patient,  as  a  matter  of  course,  claims  special  attention. 
This  treatment  we  consider  as  applicable  to  the  pathological  condi- 
tion of  the  patient,  i.  e..  congestion  of  the  capillaries,  oedema  of  the- 
connective  tissue,  dilatation  of  the  veins,  and  loss  of  vital  energy  in- 
the  superficial  tissue  of  the  parts  affected — the  lesion  being  the  result 
of  impediment  from  whatever  cause,  to  the  return  of  the  venous- 
blood  in  the  superficial  tissues  of  the  legs. 


Varicose  Veins,  etc.  265 

BURS^. 

Bursas  are  an  essential  part  of  the  animal  economy,  and  like  that 
of  other  functional  apparatus,  subject  to  abnormal  conditions,  as 
well  as  from  extraordinary  influences  which  become  developed ;  as 
in  the  instance  of  bursse  on  the  dorsum  of  the  foot  in  talipes  varus, 
and  liousemaicV s  knee.  Two  forms  of  bursse  exist,  and  two  distinct 
offices  are  performed  by  them.  They  are  known  as  humm  syuovim 
and  hurscB  mucosce.  These  bursae  are  large,  simple  or  irregular  cavi- 
ties in  the  subcutaneous  areolar  tissues,  containing  a  clear  synovial 
fluid,  and  are  found  in  various  situations  ;  as  between  the  integu- 
ment and  front  of  the  patella,  over  the  olecranon,  the  malleoli  and 
other  prominent  parts.  They  are  also  found  interposed  between 
muscles  or  tendons  as  they  play  over  projecting  bony  surfaces;  as 
between  the  glutei  muscles  and  surface  of  the  great  trochanter.  They 
consist  of  thin  walls  of  connective  tissue  partially  covered  by  epi- 
thelium, and  contain  a  viscid  fluid.  These  bursae  usually  communi- 
cate with  the  cavities  of  joints,  as  is  the  case  witli  the  bursae  between 
the  tendons  of  the  psoas  and  iliacus  and  the  capsular  ligament  of 
the  hip,  or,  the  one  interposed  between  the  under  surface  of  the 
subscapularis  and  the  neck  of  the  scapula. 

Tendons  passing  through  osseo  fibrous  canals  are  supplied  with 
synovial  sheaths.  The  sheaths  are  formed  of  two  layers,  one  of 
which  adheres  to  the  wall  of  the  canal,  and  the  other  is  reflected 
upon  the  outer  surface  of  the  contained  tendon  ;  the  space  between 
the  two  free  surfaces  of  the  membrane  being  partially  filled  with 
synovia.  These  sheaths  are  chiefly  found  surrounding  the  tendons 
of  the  flexor  muscles  of  the  fingers  and  toes,  as  they  pass  through 
the  osseofibrous  canals  in  the  hand  and  foot,  and  from  unfavorable 
influences  are  liable  to  form  a  morbid  condition. 

Stress  of  pressure,  and  friction  tends  to  the  enlargement  of  these 
bursae.  Mr.  Paget,  in  his  Surgical  Pathology,  says:  "Two  methods 
obtain  as  regards  their  formation.  Some  —  of  which  the  best 
example  is  the  bursae  over  the  patella  and  its  ligament  —  are  merely 
enlargements,  and  with  various  transformations  of  bursae  naturally 
existing.  JSTot  materially  difl;erent  from  these,  are  the  bnrsae  which 
form  anew  in  parts  subjected  to  occasional  localized  pressure,  and 
which  appear  to  arise  essentially  from  the  widening  of  spaces  in 
areolar  or  fibro-cellular  tissue,  and  the  subsequent  leveling  oi 
smoothing  of  the  boundaries  of  these  spaces;  but  others,  such  as 


256  ORTHOPjEBIA. 

the  bursse  or  ganglions  which,  form  about  the  sheaths  of  the  ten- 
dons at  the  wrist,  appear  to  be  the  cystic  transformations  of  the 
cells  inclosed  in  the  fringe-like  processes  of  the  synovial  membrane 
of  the  sheaths." 

These  bursae  undergo  various  changes  in  structure  and  contents  — 
tending  to  the  most  serious  consequences.  Special  employment  is 
a  most  common  cause  of  these  morbid  changes.  Kneeling  upon 
hard  surfaces,  as  that  of  the  floor,  occasions  enlargement  of  the 
bursse  patella — known  as  the  liousejiiaid' s  Jcnee.  Miners  also  are 
subject  to  an  enlargement  of  the  bursse  lying  over  the  olecranon, 
commonly  called  miners'  elboio,  and  in  every  situation  a  new  bursas 
may  be  formed  by  continued  pressure  and  friction  conjoined. 

These  unfavorable  changes  ensue  in  order  somewhat  as  follows: 

a.  Continued  pressure  and  friction  tend  to  enlargement  of  the 
exposed  bursas  which  becomes  filled  with  a  clear,  sero-synovial,  straw- 
colored  fluid. 

b.  Inflammation  supervenes,  tending  to  suppuration,  when  the 
contents  change  to  pus  and  bursal  secretion.  The  termination  is 
then  to  present  a  point,  and  open,  like  an  ordinary  abscess — usually 
with  a  sloughing  tendency,  often  terminating  in  a  widely  spreading 
abscess. 

c.  In  some  cases  the  bursse  will  contain  a  dark  fluid  with  a  large 
number  of  small,  flattened,  elongated  bodies  of  about  the  size  of 
grains  of  rice,  or  melon  seeds,  floating  in  it.  These  bodies  are  of 
a  fibroid,  or  fibro-plastic  structure,  resembling  masses  of  imperfectly 
developed  exudation  cells,  and  are,  apparently,  portions  of  disinte- 
grated lymph. 

d.  The  tendency  of  the  bursal  tumor,  in  some  cases,  is  to  become 
perfectly  solid  ;  the  walls  becoming  thickened  by  the  disorganized 
lymph  in  its  interior.  When  this  condition  supervenes,  then  a 
section  of  the  bursse  presents  a  solidified,  laminated  appearance. 

e.  As  bursse  become  elastic,  they  have  a  crackling  sound  on 
being  pressed,  and  more  especiallywhen  they  contain  the  rice-shaped 
bodies  tending  to  a  solid  growth.  The  inflammation  in  the  diseased 
bursse  often  extends  to  the  neighboring  joint  from  simple  contin- 
uity—there being  no  other  connection;  or  inflammation  and  sup- 
puration may  exist  within  the  cavity  of  the  joint,  and  in  the  bursse, 
having  no  connection  ;  as  in  the  case  of  strumous  conditioned 
patients.  These  adventitious  rice-shaped  bodies  often  become  a 
source  of  severe  suffering,  when  formed  within  the  capsular  ligament 


Varicose  Veins,  etc.  257 

of  the  knee,  from  thence  floating  within  the  bearing  of  the  joint 
when  in  the  erect  position,  as  in  walking,  affecting  the  individual 
instantaneously,  and  the  pain  so  intense  as  to  cause  them  to  fall  as 
if  shot. 

TEEATMENT   OF    BURS^. 

In  the  first  tendency  to  increase  of  development  in  an  exposed 
bursse,  a  removal  of  the  cause,  and  gentle  pressure  affords  perma- 
nent relief ;  and  in  many  instances,  in  advanced  cases,  pressure 
and  rest  is  a  reliable  treatment.  When  much  inflammation  has 
supervened,  leeches,  and  tepid  lotions  containing  acetate  of  lead 
will  arrest  the  abnormal  tendency. 

When  suppuration  takes  place,  and  they  are  in  an  indolent  con- 
dition, cloths  saturated  with  water  at  a  temj)erature  of  60°,  holding 
in  solution  a  drachm  of  fluid  ext.  belladonna  and  two  drachms 
of  tr.  iodine  to  the  quart,  kept  wet  and  secured  with  tolerable 
pressure,  may  be  used  with  decided  advantage  ;  and,  when  the 
patient's  condition  is  such  as  to  admit  of  saline  purgatives,  they 
should  be  given  freely,  or,  calomel  and  jalap,  of  each  eight  grains 
to  the  dose.     This  treatment  will  often  tend  to  a  cure. 

When  the  sac  is  thin,  and  the  fluid  serous  from  recent  injury, 
blistering  is  often  an  effectual  remedy;  and  especially  when  it 
occurs  under  the  deltoid  muscle.  The  passage  of  a  small  seton 
through  the  sac,  and  making  a  decided  elastic  pressure  by  means  of 
raw  cotton,  and  a  laced  bandage,  as  that  of  the  knee  bandage  de- 
scribed in  another  part  of  this  work,  is  quite  a  reliable-  means  of  re- 
lief in  non-strumous  or  scorbutic  subjects.  If  of  strumous  diathesis, 
violent  inflammation  often  follows  the  insertion  of  the  seton. 
Dynamic  electricity,  as  an  auxiliary,  often  contributes  largely  to 
the  cure  when  in  the  suppurative  condition  —  bearing  in  mind  the 
oareful  enforcement  of  hygiene  regime,  and  alterative  tonics  ;  as 
that  of  tr.  cinchona  and  bichloride  of  mercury,  and,  if  deemed 
advisable,  iodide  of  potassium  ;  carefully  regarding  the  constitution 
of  the  patient. 

The  pathology  of  chronic  enlargements  of  bursee  is  given  by  Mr. 
Erichson  as  follows  :  "  There  is  an  enlargement  of  the  bursse,  and 
excessive  secretion  into  its  interior  of  simpler  synovial  fluid  ;  this, 
however,  is  discolored,  probably  from  admixture  of  blood  which 
has  undergone  disintegration.  This  fluid  will  be  found  to  contain 
a  large  quantity  of  cholesterine,  broken  up  blood  corpuscles,  and 


258  OrTHOPjEBTA. 

granules.  The  melon  seed  bodies  are  composed  of  largely  organized 
fibroid  matter  mixed  with  cholesterine,  and  are  probably  separated 
from  the  serum  of  the  bursse. 

"Solid  tumors  may  be  formed  in  connection  with  the  bursas 
patellae.  By  many  these  are  supposed  to  be  the  result  of  the  deposi- 
tion of  a  fibroid  material  which  gradually  takes  the  place  of  the 
fluid  of  an  ordinary  housemaid's  knee,  and  which,  instead  of  taking 
the  form  of  melon-seed  bodies,  is  deposited  in  concentric  masses, 
and  thus  accumulated  in  the  interior  of  the  cyst.  This  has  not 
been  the  case,  however,  in  many  instances  that  I  have  seen.  In 
these  cases  I  believe  there  is  a  true  fibroid  deposit  in  the  bursse  from 
the  very  first ;  the  tumor  is  never  fluid,  but  hard  and  solid  from 
the  commencement,  and  continues  to  slowly  augment  in  size  until 
it  occasions  sufficient  inconvenience  to  require  removal.  In  some 
cases  there  has  been  a  previous  syphilitic  taint;  the  patient  com- 
plains of  pain  in  the  tumor  like  that  which  is  experienced  in 
nodes,  and  it  is  by  no  means  impossible  that  there  may  be  a  syphili- 
tic origin  for  these  tumors.  However  that  may  be,  in  the  casts 
that  have  fallen  under  my  observation,  the  tumors  have  never  been 
fluid,  nor  have  they  originated  in  pressure,  but  appear  to  have  been 
primary  deposits  of  fibroid  matter." 

The  treatment  for  these  solid  tumors  is  plainly  indicated;  that 
of  dissecting  them  out,  carefully  avoiding  the  opening  of  the 
capsular  surroundings  of  the  joint.  Constitutional  treatment  is 
considered  indispensable  to  their  future  v/elfare.  When  in  the 
ordinary  fluid  condition  elastic  compression  by  the  application  of 
cotton,  bathing,  and  the  lace  bandage  before  described,  is  the  most 
safe  and  reliable  treatment.  Static  electricity  conjoined  renders 
the  bandaging  more  efiectual  in  promoting  absorption  of  the  dis- 
tending fluids. 


GANGLION. 
DISEASES   OF   SHEATHS   OF   TENDONS. 

The  sheaths  of  tendons  are  subject  to  two  forms  of  disease,  viz. 
An  accumulation  of  fluid  within  the  interior  of  the  sac,  known  as 
cystic  swelling,  or  ganglioji.  and  acute  and  chronic  inflammation,  or 
serocystitis.     The  common  ganglion  consists  of  a  cyst  containing 


Varicose  Veins,  etc.  259 

a  clear  or  yellowish  colored  serous,  and  in  some  cases,  gelatinous 
and  semi-coagulated  fluid.  They  usually  occur  on  the  back  of  the 
wrist  in  the  form  of  a  distinct,  round  tumor,  distinctly  formed 
within  the  sheaths  of  the  tendons,  and  are  at  times  found  upon  the 
foot  and  wherever  tendons  are  thinly  covered  by  external  integu- 
ment—  greatly  impairing  the  strength  of  the  joints  over  which 
they  may  be  located;  and,  from  increasing  in  dimensions,  press 
upon  the  nerves;  inducing,  in  some  instances,  considerable  pain, 
especially  when  located  upon  the  back  of  the  wrist,  by  compressing 
some  of  the  branches  of  the  musculo-spiral  nerve. 

The  palm  of  the  hand,  dorsum,  sole,  and  inner  side  of  the  foot 
are  subject  to  ganglion.  In  these  locations  they  consist  of  a  dila- 
tation of  the  sheaths  of  the  tendons,  and  often  increase  to  a  large 
size,  becoming  irregular  in  shape  from  the  implication  of  several 
tendons  in  the  tumor.  The  contained  fluid  is  usually  thinner  than 
in  simple  ganglion  or  ganglion  confined  to  a  single  tendon.  The 
sheath  itself  is  vascular,  and  lined  by  a  red,  fringed  and  velvety 
membrane;  the  fluid  is  often  dark  and  bloody,  containing  masses 
of  bufl-colored  fibrin,  or  a  large  number  of  granular  bodies  like 
those  met  with  in  certain  form  of  enlarged  bursse.  This  is  a  most 
serious  condition  of  the  ailment;  having  a  malignant  appearance 
and  being  chronic  in  character. 

Ganglion,  when  situated  in  the  palm  of  the  hand,  usually  extends 
under  the  annular  ligament  and  upon  the  flexor  tendons  of  the 
fore-arm,  and  is  extremely  hazardous  in  treatment;  an  uncontrol- 
lable inflammation  being  most  readily  induced,  to  the  great  injury 
of  the  hand.  The  fluid  in  the  ganglion  in  this  location  is  most 
readily  pressed  into  the  palm  of  the  hand,  or  from  the  palm  of  the 
hand  into  the  sheaths  of  the  flexor  tendons  above  the  wrist. 

TEEATMEKT. 

The  treatment  of  simple  ganglion  on  the  back  of  the  wrist  is 
most  readily  accomplished  by  a  blow  from  the  hard  cover  of  a  book. 
Bending  the  wrist  so  as  to  render  the  integument  over  the  ganglion 
very  tense,  and  then  striking  it  with  some  force  it  is  dispersed,  and, 
usually,  without  further  disturbance.  It  can  also  be  disposed  ot 
by  pressure  from  a  small  piece  of  metal  placed  over  the  ganglion 
and  bound  down  as  tightly  as  can  be  borne.  This  is  a  more  tedious 
treatment,  and  no  more  safe  than  that  of  rupturing  the  tumor  with 
the  book.     The  other  means  of  procedure  are  often  attended  ^\\t\t 


260  OllTROP.^BlJl. 

more  or  less  serious  consequences.  They  consist  in  puncturing, 
and  the  insertion  of  setons,  thereby  exciting  inflammation,  as  in 
that  of  bursas,  the  indication  of  each  demanding  similar  treatment. 

The  ganglion  located  in  the  palm  of  the  hand  and  extending 
under  the  annular  ligament,  and  up  the  flexor  tendons  of  the  fore- 
arm, presents  much  difficulty  in  the  treatment,  and  always  an  aj)- 
prehension  of  serious  consequences;  violent  inflammation  being 
most  readily  excited  from  puncturing  or  the  insertion  of  a  seton, 
which  is  the  ordinary  treatment.  Mr.  Syme  recommends  that  the 
cyst  should  be  laid  open  and  the  annular  ligament  divided.  This 
is  certainly  decided  treatment,  and  must  be  attended  with  as  much 
difficulty  and. tendency  to  inflammation  as  the  practice  of  punctur- 
ing—  if  not  more  —  and  is  certainly  more  painful  to  the  patient, 
and  should  command  much  serious  consideration 

Prof.  Frank  H.  Hamilton  states,  in.  his  most  invaluable  work  on 
the  "Principles  and  Practice  of  Sui'gery,"  in  regard  to  free  in- 
cision, injection  and  excision,  that  they  ai"e  all  liable  to  be  followed 
Tdv  violent  inflammatory  reaction,  and  even  by  sujDpru-ation,  which 
is  readily  propagated  along  the  course  of  the  tendons,  and  may 
therefore  endanger  even  the  life  of  the  patient.  These  remarks 
are  also  applicable  to  the  same  methods  of  treatment  of  palmar 
bursse. 

This  Aiew  of  the  subject  I  can  freely  verify  in  the  loss  of  a  sur- 
g'eon,  an  intimate  friend  of  mine,  whom  I  cautioned  not  to  have 
a  palmar  bursa  in  his  hand  laid  open,  as  advised  by  several  eminent 
surgeons,  and  in  having  it  done  lost  his  life. 


CHAPTER  XI. 

ETIOLOGY  OF  CONSTITUTIONAL  DYSCRASIA. 

Constitutional  dyscrasia  tending  to  chronic  invasion  of  tissues. — Struma  with 
and  without  tubercle. — Views  of  Dr.  "William  Goulson. — Hemorrhagic  tendency 
in  this  class  of  patients. — Scorbutic  tendency  hereditary;  illustrative  case. — 
Hyperpathia  noted  by  Coulson  and  Sir  Benjamin  Brodie. — Genera!  fatality  of  hip 
disease  in  patients  of  decidedly  tubercular  strumous  diathesis. — Prognosis  more 
favorable  in  scorbutic  patients;  illustrative  case. — Post-mortem  case  reported 
by  Mr.  Key. — Vesication  as  a  derivative  in  acute  hip  disease. — Extension  weight 
a  palliative  only. — In  scorbutic  cases  the  synovial  membrane  is  first  invaded. — 
Periostitis  of  the  long  bones  often  the  result  of  mechanical  injury. — Scorbutus 
observed  in  the  growth  of  the  teeth  and  congestion  of  the  gums. — Hemorrhages 
common  on  slight  provocation;  illustrative  case. — Prof.  H.  Immerman's  views 
on  this  subject. — Scorbutus  is  distinct  from  haemophilia  pathologically. — Refer- 
ence to,  with  extracts  from,  Prof.  M.  L.  Knapp's  dissertation  on  nursing  sore 
mouth. — Observations  of  Sir  Gilbert  Blane,  Marshal  Hall  and  Eberle  on  land 
scurvy,  with  deductions  therefrom. — Proper  ventilation  and  hygiene  indispen- 
sable in  treatment.— Remarkable  low  death-rate  in  the  Hospital  for  the  Relief  of 
the  Ruptured  and  Crippled  during  the  past  twenty  years. — Case  illustrative  of 
strumous  diathesis,  with  report  of  the  post-mortem,  and  engraving  showing 
section  of  the  diseased  bone. — Deductions  drawn  from  above. — Case  of  com- 
pression of  the  spinal  cord,  from  Potts'  disease. — Tables  verifying  the  condition 
of  the  5.461  cases  treated. — Ventilation  and  hygiene  of  the  Hospital  for  the  Relief 
of  the  Ruptured  and  Crippled. 


PRIMARY    CONDITION     TENDING    TO    LOCAL   INVASIONS    OF    THE   CELLULAR   AND 

OSSEOUS    TISSUES. 

A  dysthesia  of  the  system  may  be  reasonably  considered  as  tend- 
ing to  local  invasion  of  any  part  of  the  body  or  limbs.  Hypersemia 
is  the  first  indication,  followed  by  congestive  determination  and 
inflammation,  and  this  the  result  of  a  traumatic  incident,  in  many 
cases  so  trivial  as  not  to  be  noticed  at  the  time,  and  only  remem- 
bered vrhen  the  part  has  become  painful,  indicating  the  constitu- 
tional tendency  to  a  progressive  invasion,  the  ordinary  means  of 
relief  having  failed.  An  increase  of  temperature  in  the  part,  above 
that  of  other  parts  of  the  body,  is  usually  detected,  indicating  an 


262  Orthop^dia. 

interrupted  circulation  in  the  capillaries.  The  part  invaded  be- 
comes sensitive  to  the  touch,  but  in  most  instances  there  is  no 
change  of  color,  if  about  the  joint.  The  patient  is  often  conscious 
of  a  dull  aching  sensation  in  it,  scarcely  amounting  to  pain,  but 
attended  with  uneasiness.  In  others,  of  similar  apjDcarance,  it  is  at- 
tended with  acute  pain  and  excessive  suffering.  The  effects  of  con- 
gestion are  now  apparent,  and  the  effort  in  the  obstructed 
circulatory  system  is  to  obtain  relief  by  transudation  of  the  more 
watery  constituents  of  the  blood,  and  thus  effused  in  the  surround- 
ing cellular  tissues,  tending  to  oedema,  the  result  of  infiltration  in 
the  cells,  often  tending  to  softening,  and  an  arrest  of  nutrition,  as 
seen  in  invasion  of  the  hip  and  synovitis  of  the  knee.  The  limb 
becomes  attenuated  in  the  early  stage  of  the  invasion,  and  the 
superficial  veins  are  dilated.  In  this  condition  hypersth-enia  tends 
to  severe  pain  in  the  invaded  jorats. 

This  dysthesia  presents  various  conditions  in  very  noticeable 
constitutional  tendencies,  inviting  special  consideration  in  regard 
to  the  constitutional  predisposition  or  dyscrasia  of  the  system. 
Struma,  under  the  ordinary  accej^tation  of  writers,  presents  two  con- 
ditions— strumous  and  scorbutic — one  of  struma  ivith  tubercles,  the 
other  void  of  tubercles.  WiUiam  Coulson,  Surgeon  to  the  Magdalen 
Hospital,  Constdting  Surgeon  to  the  City  of  London  Lying-in  Hos- 
pital, FeUow  of  the  Koyal  Medico-Chirurgical  Society  of  Berlin,  a 
very  noted  writer  on  hip  disease,  states :  "  If  the  complaint  occurs 
in  a  scrofulous  subject,  the  inflammatory  action  will  be  very  much 
modified  by  this  state  of  the  constitution.  It  is  known,  however, 
that  in  this  and  many  scrofulous  diseases,  the  inflammatory  diathesis 
is  indolent  during  the  first  attack,  and  is  not  discovered  by  the 
usual  symptoms  of  acute  j^in  and  fever.  On  the  contrary,  in  per- 
sons who  are  not  of  a  scrofulous  habit,  the  local  and  constitutional 
symptoms  are  much  more  severe."  I  can  most  fuUy  sustain  this 
statement  in  the  treatment  of  hip  disease,  in  which  the  greater 
number  being  in  the  incipient  stage  of  the  invasion  of  hip  and 
other  joint  diseases,  severe  sensitiveness  presented;  so  much  so, 
that  even  walking  on  the  floor  would  greatly  agitate  the  patient  and 
cause  great  distress,  whilst  in  the  advanced  stages  there  is  great 
sensitiveness  to  the  most  tender  handhng.  The  constitutional 
history  of  this  class  of  patients  is  that  they  had  a  hemorrhagic 
tendency;  the  free-flowing  saliva  during  the  night  would  soil  the 
pillow-case  with  bloody  saliva,  from  inflamed  nares,  swollen  gums, 
and  aphthous  ulcer  of  the  fauces.     In  phj^sical  form,  when  young, 


Etiology  of  Constitutional  Dtscrasia.  263 

these  children  are  delicate  and  subject  to  fetid  ulceration  of  the 
mouth  and  pain  in  the  ears.  The  family  history  of  this  scorbutic 
diathesis  I  have  seen  distinctly  manifested,  and  the  hereditary 
sequence  of  a  most  patent  type.  The  father,  a  true  type  of  the 
scorbutic  diathesis,  who,  when  a  child,  had  caries  of  the  sjDine  and 
diseased  os  calcis,  from  which  he  recovered,  since  then  has  had 
frequent  attacks  of  hsematemesis,  swollen  joints  and  ulceration  of 
gums,  attended  with  severe  pain  and  tenderness.  He  has  been 
under  my  observation  for  eighteen  years,  and  is  the  father  of  ten 
children,  five  of  whom  have  died  in  infancy,  and  the  five  now  hving 
have  all  bleeding  gnims,  and  soil  the  pillow  at  night  with  bloody 
saliva.  This  is  a  very  marked  incident  of  hereditary  sequela ;  and 
I  have  seen  numerous  other  cases  of  this  noted  hyperpathia  noticed 
by  most  eminent  authorities,  as  state^d  by  Coulson  and  Sir  Ben- 
jamin Brodie.  "If  the  patient  is  not  that  kind  of  a  person  whom 
one  would  judge  to  be  predisposed  to  what  is  called  scrofula,  it 
would  be  a  reason  for  suspecting  that  it  is  not  a  case  of  strumous 
affection  of  the  bone.  Again,  if  the  patient  be  about  twenty-five 
years  of  age,  it  is  more  likely  that  he  will  have  simple  ulceration  of 
the  cartilage  than  the  true  scrofulous  disease.  Another  important 
diagnostic  mark  is  this  :  A  much  greater  amount  of  pain  attends 
the  disease  in  its  early  stage  in  case  of  simple  ulceration  of  the 
cartilage  than  where  the  ulceration  is  combined  with  scrofulous 
disease  of  the  bone.  One  of  the  most  remarkable  circumstances 
connected  with  scrofulous  disease  of  the  bone  is  that  there  is  so 
little  pain  in  the  first  instance,  the  patient  going  on  for  weeks,  and 
yet  the  disease  being  scarcely  noticed.  But  in  simple  ulceration 
there  is  generally  severe  pain  at  an  early  period.  In  scrofulous 
disease  of  the  bone  you  have  very  little  pain  in  general  till  the  car- 
tilages are  extensively  ulcerated  and  purulent  matter  begins  to 
form,  but  in  the  other  cases  there  is  a  great  deal  of  jDain  long  before 
that  period  has  arrived."  This  latter  condition  of  patients  laboring 
under  hip  disease,  of  which  I  have  had  the  supervision  of  seven  hun- 
dred and  twenty-four  cases  in  the  Hospital  for  the  Relief  of  the  Rup- 
tured and  Crippled,  and  whole  number  of  in  and  out  jDatients  2,943. 
The  scorbutic  proved  to  be  the  most  susceptible  of  relief  from  the 
progressive  invasion,  and  are  the  most  numerous  of  those  affected 
with  joint  disease.  It  is  the  exception,  in  my  experience,  to  be  suc- 
cessful in  arresting  joint  disease  in  patients  of  a  decidedly  tuber- 
cular strumous  diathesis.  They  linger  for  months,  and  die  from 
exhaustion,  the  result  of  draining  sinuses,  phthisis  pulmonaHs,  dis- 


264 


Orthop^bia. 


Fig   105. 


eased  liver,  and  anasarcous  swelling  of  the  lower  extremities.  In 
all  this  decay  of  the  body  and  limbs,  pain  is  but  seldom  mani- 
fested by  the  patient. 

Scorbutic  patients  endure  a  large  amount  of  draining  from  ex- 
tensive sinuses,  and  yet  recover;- but  in  the  future  have,  from  time 
to  time,  attacks  of  erysipelas,  enlarged  and  swollen  joints,  with 

extreme  suffering,  through 
which  they  live  an  ordinary 
life-time.  The  following  en- 
graving represents  a  case  of 
most  extensive  ulceration  after 
di-aining  sinuses  from  chronic 
synovitis  of  left  knee;  the  leg 
flexed  upon  the  thigh;  separa- 
tion between  heel  and  tuber 
ischii  three  inches;  knee-joint 
much  enlarged,  and  not  the 
slightest  apjDearance  of  inflam- 
mation. It  is  the  case  of  a 
girl,  nine  years  of  age,  who 
had  been  suffering  for  fifteen 
months  with  this  disease  of 
the  knee  in  a  most  miserable 
habitation  ;  an  intemjoerate 
father,  and  a  hard-working 
mother  unable  to  procure 
proper  nourishment  for  her 
child,  who  was  subsequently 
admitted  into  the  Hospital  for  the  Relief  of  the  Ruptured 
and  Crippled,  in  which  she  remained  three  years,  and  was 
reUeved,  as  seen  in  the  engraving.  It  is  now  sixteen  years 
since  the  joatient  left  the  hospital;  is  in  an  excellent  condition 
of  health,  limited  motion  in  the  knee-joint,  but  walks  with 
scarcely  a  perceptible  hmp.  The  girl  has  had,  at  times,  ery- 
sipelas in  the  limb  and  tender  gums.  In  this  case  there  was*  no 
bone  invasion,  the  disease  being  most  active  in  the  synovial  mem- 
branes of  the  joint  and  extending  to  the  cellular  tissues,  as  seen 
from  the  extensive  sinus  openings  in  the  thigh  and  the  cicatrices 
below  the  knee.     (See  colored  engraving  in  front  of  book.) 

In  scorbutic  invasions  of  the  hip  and  typical  cases,  where  an 
examination  was  made  after  death,  I  can  only  refer  to  a  case  re- 


PLATE   II 


3— Round   Libameni'  in  a  hi0h  sfal"e  of  inrlammal-ion. 
b—Ulcerat"ed  spol-  on  |-he  carhila^e. 
c__lnfiamed  synovial  membrane. 


Bisec^ion  of  same  bone. 


SACKETl  WUHE'.MSi  BEIZIG  45-51  ROSi 


Etiolog  y  of  Constitutional  D  yscrasia  .  265 

ported  by  Mr.  Key  and  quoted  by  Mr.  Coxilson.*  "  The  case  that 
has  fallen  to  my  lot  to  examine  has  induced  me  to  beheve  that  the 
ulceration  of  the  cartilage  is  preceded  by  inflammation  of  the  liga- 
mentum  teres.  In  the  early  stage  of  this  disease,  which  I  lay 
before  the  Society,  will  be  seen  the  usual  morbid  appearance  that 
I  have  met  with."  Here  he  presents  a  beautiful  engraving, 
with  the  natural  coloring  of  the  diseased  joint,  a  copy  of 
which,  with  grateful  acknowledgment  to  the  author,  I  have 
inserted- — colored  lithograph.  He  proceeds  as  follows:  "This 
joint  was  taken  from  a  young  female  who,  for  six  months 
prior  to  her  death,  had  labored  under  the  usual  symptoms 
of  chronic  inflammation  of  the  hip-joint.  The  symptoms  had 
partly  yielded  to  the  treatment  employed,  when  she  was  at- 
tacked with  another  disease,  of  which  she  died.  The  ligamentum 
teres  was  found  much  thicker  and  more  pul]Dy  than  usual  from 
interstitial  effusion,  and  the  vessels,  upon  inverting  synovial  mem- 
brane, were  distinct  and  large,  without  being  filled  with  injection. 
At  the  root  of  the  ligament,  where  it  is  attached  to  the  head  of  the 
femur,  a  spot  of  ulceration  in  the  cartilage  is  seen,  commencing,  as 
it  does,  in  other  joints,  by  an  extension  of  the  vessels  in  form  of  a 
membrane  from  the  root  of  the  vascular  ligament.  The  same  pro- 
cess was  also  taking  place  on  the  acetabulum,  where  the  ligamen- 
tum teres  is  attached."  There  is  represented  a  vertical  section  of 
the  head  of  the  os  femur,  as  described;  there  is  no  disease  to  be 
found  in  the  cancellated  portion,  and  only  an  ulcerated  spot  in  the 
cartilage. 

Mr.  Coulson  describes  another  case  of  a  child  twenty  months 
old,  and  cutting  its  teeth,  in  which  he  found  that  disease  was  going 
on  in  the  hip:  "The  trochanter  was  thrown  more  forward;  the 
nates  were  more  projecting;  the  leg  was  bent  on  the  thigh  and  the 
thigh  on  the  pelvis;  and  the  child  rested  on  the  opposite  side,  and 
appeared  in  great  pain,  not  allowing  the  joint  to  be  in  any  way 
moved;  treatment  for  the  time  being  afforded  relief.  The  child 
went  on  in  this  state  of  suffering  until  the  13th  of  June  last,  when  it 
was  seized  with  convulsions,  and  it  died  on  the  following  morning. 
In  the  evening  I  examined  the  body  with  Mr.  King,  of  Cateaton 
Street,  under  whose  care  the  child  had  latterly  been.  On  measur- 
ing both  limbs,  we  found  the  right  a  little  shorter  than  the  left. 
The  muscles  in  the  posterior  region  of  the  joint  were  much  atten- 

*  Medico-Chirurgical  Transactions,  vol.  xviii.,  p.  230. 


266  Ortmop^dia. 

uated  as  compared  with  those  on  the  opposite  side.  On  opening 
the  capsular  ligament  some  thick  yellowish  matter  escaped, 
resembhng  in  consistence  the  cortical  substance  of  the  brain.  The 
quantity  amounted  to  half  a  tablespoonful.  The  round  ligament 
was  completely  destroyed,  and  the  synovial  membrane  inflamed. 
There  was  absorption  of  some  portion  of  the  cartilage  covering  the 
head  of  the  femur,  and  of  the  cartilaginous  rim  of  the  femur;  the 
bone  was  found  healthy  and  the  cartilage  no  further  diseased.  The 
left  hip  was  quite  healthy.     (See  colored  lithograph.) 

A  practical  consideration  here  presents,  in  the  relief  afforded  in 
acute  hip  disease  from  vesication  an  a  derivative — my  common  practice 
in  such  cases— having  the  ordinary  Spanish  fly  blister  applied  for  eight 
hours  and  of  not  less  than  f oui*  by  four  inches  in  size,  then  poulticed 
with  ground  flaxseed,  frequently  changed,  for  at  least  thirty-six  hours. 
Patients,  mostly  children,  received  in  our  hospital  in  most  extreme 
suffering,  having  failed  to  sleejD  for  many  hoiu's,  and  so  sensitive  as 
to  scream  fi'om  the  agitation  of  walldng  in  the  room  or  the  touch- 
ing of  the  bed,  will  in  nearly  all  instances  be  relieved  in  from  two 
to  three  hours  after  the  bhster  has  been  applied,  but  in  some  cases 
not  quite  so  soon.  I  do  not  know  of  a  failure  after  the  second  or 
third  change  of  the  poultice  has  been  made.  This  has  been  my 
experience  for  the  past  thirty  years  in  the  incipient  stage  of  the 
disease,  and  hence  I  have  not  apphed  extension  weight  to  reheve 
pain  in  the  hip,  which  treatment  I  consider  as  only  palliative  and 
not  curative,  as  regards  the  deej)  seated  congestion  in  and  about 
the  joint.  I  beheve  the  early  invasion  to  be  in  the  synovial  mem- 
brane of  the  hip-joint,  in  scorbutic  cases,  and  sustained  in  my 
diagnosis  by  Mr.  Coulson  and  many  other  writers  on  this  subject. 
IVIr.  Coulson,  in  his  treatise  on  hip  disease,  page  49,  says :  "  That 
the  synovial  membrane  of  the  hip-joint  is  often  primarily  engaged 
in  this  disease,  we  may  infer  from  one  of  the  first  syiliptoms  which 
marks  its  commencement,  a  fullness  of  the  groin,  depending  in  all 
probability  upon  the  increased  secretion  into  the  joint,  similar  to 
that  which  -^re  know  takes  j)lace  in  synovitis  of  the  knee."  And 
why  not  ?  The  knee  is  reheved  by  vesication  and  poulticing  in  the 
acute  stage.  The  reverse  often  follows  vesication  from  having 
stimulant  ointments  appHed  as  dressing,  which,  I  believe,  induce  a 
tendency  to  increase  the  inflammation  of  the  diseased  joint,  by  tend- 
ing to  morbid  excitement,  and,  finally,  a  chi'onic  condition. 

The  periosteum  of  the  long  bones  is  as   commonly  invaded  as 
that  of  the  synovial  membrane  of  the  joints,  especially  that  of  the 


PLATE    III 


Synovial  mem- 
brane inflamed. 

d_Margin  of 
Acet-abulum. 

e^Purulenl- 
SecreMori. 


a-Ulcerahion  oP  t-he 
Carhilage  oP  head 
of   Pemur. 

b^ReFleched  capsular 
ligamenl-  ext-ending  ^o 
ulcerafed  spol"  in  ^he 
carh'lage. 


SACKETl  W1LHELMS&  BLFZIG  45-51  ROSE  ST  N.Y, 


Btiolooy  of  Constitutional  Dyscbasia.         267 

tibia  on  its  anterior  surface,  that  of  the  ribs,  the  scapula,  the  in- 
ferior maxillary  as  well  as  the  palatine  processes  of  the  superior 
maxillary  bone.  These  affections  of  the  periosteum,  which  are 
generally  circumscribed  in  character,  occur  relatively  often  as  the 
result  of  some  mechanical  injury  that  has  befallen  the  bones;  they 
also  sometimes  occur  without  any  apparent  cause  in  cases  of  con- 
stitutional dyscrasia.  They  present  in  swellings,  exceedingly 
painful,  and  with  some  degree  of  hardness,  which  have  their  origin 
a,t  times  in  inflammatory  hemorrhagic  effusion  of  the  periosteum, 
and  after  a  time  reabsorbed.  In  unfavorable  cases  periostitis 
terminates  in  necrosis  of  the  bone  affected,  and  yet  may  not  involve 
the  joint.  It  is  stated  that  scorbutic  affections  tend  to  softening  of 
the  cells  of  united  fracture  of  the  long  bones.  This  is  the  observa- 
tion of  such  eminent  authorities  as  Aitkin,  Pringer,  Bell,  Levelle  and 
Kiebel.  Scorbutus  is,  in  some  instances,  observed  in  the  growth 
of  children's  teeth  when  in  a  feeble  condition  of  health,  and  the 
teeth  slowly  advancing,  a  distinct  demarkation  is  made  upon  them, 
and  on  the  improvement  of  their  health;  the  subsequent  growth 
will  be  more  perfect,  presenting  in  appearance  a  peculiar  condi- 
tion, very  perceptible  on  the  teeth  in  after  life,  the  upper  portion 
being  darker  in  color  than  that  of  the  after  growth.  The  scorbutic 
affections  of  the  gums,  a  limited  line  of  red  and  fading  shades,  is 
the  most  frequent  and  generally  the  earliest  local  indication  of 
scurvy. 

The  histological  changes  in,  and  the  clinical  appearance  of  the 
gums,  even  in  the  slighter  forms  of  the  affection,  show  that  there  is 
a  decidedly  inflammatory  tendency,  which  begins  with  hypersemia 
and  exhaustion  of  the  blood,  that  presents  the  redness  and  painful 
swelling  of  the  parts  affected.  Hence  dangerous  hemorrhage  that 
sometimes  follows  the  extracting  of  teeth  in  such  subjects.  Two 
children,  brother  and  sister,  in  the  Hospital  for  the  Relief  of  the 
Ruptured  and  Crippled — the  girl  eight  and  the  boy  ten  years  of 
age — the  former  having  necrosis  of  the  tibia,  and  the  latter  hip 
disease,  each  showing  distinctive  indication  of  scorbutus;  the  boy 
had  defective  teeth  and  suffered  much  pain;  a  tooth  was  extracted, 
and  excessive  bleeding  followed,  so  that  even  plugging  the  socket 
only  moderated  the  flow  of  blood;  astringents  applied  to  the  gums 
after  a  time  arrested  the  bleeding.  This  is  only  a  representation  of 
many  other  similarly  conditioned  cases  that  I  have  seen  and  treated. 

Professor  H.  Immerman,  of  Basel,  a  very  intelligent  writer, 
states:    "The   question   whether  this  extravasation   of  red  blood 


268  Orthop^bia. 

corpuscles  into  the  tissues  of  the  mucous  membrane  owes  its 
origin,  like  the  traumatic  bleeding  of  the  gums,  to  a  rexis  of  the 
capillaries,  or,  in  addition  to  this,  also  to  a  simple  diapedesis 
through  the  injured  walls  of  the  capillaries,  must  remain  in 
abeyance,  since  this  special  point,  which  is  without  any  great  im- 
portance for  the  understanding  of  the  process,  has  not  yet  been 
cleared  up.  In  general,  however,  we  may  deduce  from  the  symp- 
toms which  exist  the  positive  conclusion  that  the  character  of 
scorbutic  stomatitis  is  hemorrhagic,  which  indicates  a  diseased  con- 
dition (abnormal  fragility,  combined,  perhaps,  with  abnormal  perme- 
ability of  the  capillaries)."  This  author  further  states  that  the 
number  of  isolated  observations  prove  that  not  only  are  the  dis- 
eased gums  the  primarj^  indication,  but  actually  absent  during  the 
entire  course  of  the  disease,  and  when  other  most  destructive 
features  present,  as  in  that  of  the  abnormal  condition  of  the 
mucous  membrane  of  the  entire  alimentary  canal,  or  serous  mem- 
branes of  joints  and  in  the  extremity  of  joint  invasion,  the  disease 
terminates  in  hemorrhagic  dysentery  or  purpura  hsemorrhagica,  of 
which  we  have  had  cases  in  the  Hospital  for  the  Relief  of  the 
Ruptured  and  Crijjpled.  Yet,  scorbutus  is  quite  a  distinct  patho- 
logical condition  from  that  of  hcemophilia,  and  must  not  be  con- 
founded with  that  hereditary  ailment  of  a  more  decided  hemor- 
rhagic tendency. 

The  literature  upon  the  subject  of  scorbutus  in  this  country  is  ex- 
ceedingly limited.  Prof.  M.  L.  Knapp,  President  of  the  College  of 
Physicians  and  Surgeons  of  the  University  of  Iowa,  has  written  a  disser- 
tation upon  scorbutus  as  "  Inquiring  into  the  Nature  of  the  Nursing 
Sore  Mouth  Affection,"  which  has  elicited  several  able  papers  from 
American  practitioners,  from  which  I  have  availed  myself  of  their 
expressed  views  and  experience.  Dr.  Marshall  Hall  published 
a  treatise  on  this  ailment  in  1820,  which  was  reviewed  in  the 
London  Medical  and  Physical  Journal  for  July,  1820,  with  copious 
extracts  on  this  anomalous  disease  : — Cases  of  a  serious  affection, 
occurring  chiefly  after  delivery,  an  affection  unconnected  with  the 
puerperal  state — a pueiyeral  ancemid  having  all  the  indications  of 
chronic  scorbutus,  confined  to  unfavorable  locality  of  habitation  for 
its  active  stage,  as  presented  and  described  by  Prof  Knapp  as  an 
endemic  in  an  unhealthj^  location  of  country.  Its  pathology,  in  his 
judgment,  which  agrees  with  that  of  other  medical  writers,  as  in 
that  of  my  own,  is  that  it  is  a  lesion  of  nutrition  of  grave  and 
chronic  character;  ulcerated  mouth  and  tongue,  attended  with  pro- 


Etiology  of  Constitutional  Dyscrasia.         269 

fuse  salivation,  not  mercurial;  impoverished  state  of  the  blood — the 
cause  of  the  disease — and  to  supply  the  circulation  with  normal 
elements,  the  chief  indication  in  the  treatment.  It  is  an  observed 
fact  that  infants  at  the  breast,  in  the  majority  of  cases,  are  also 
affected  with  sore  mouth.  Man}'  writers  upon  this  supposed  new 
form  of  disease  are  all  of  the  same  opinion  as  to  its  being  a  consti- 
tutional dyscrasia.  Dr.  Knapp's  conclusions  are  stated  as  follows: 
"  1.  The  nursing  sore  mouth  is  not  an  affection  pecuHar  to  nui'sing 
women.  2.  It  manifests  itself  epidemically  after  cold  protracted 
winters.  3.  Males  are  sometimes  its  subjects.  4.  The  local  lesions 
are  secondary.  5.  The  vegetable  acids  and  salt  of  potash  are 
effectual  remedies.  These  points  we  think  are  clearly  established, 
to  say  nothing  of  the  balance  of  the  testimony,  all  tending  in  the 
same  direction,  and,  as  we  think,  conclusively  proving  that  this 
anomalous  affection,  fibich  has  not  invited  attention  from  the  pro- 
fession in  Europe  or  America  for  the  last  thirty  years,  is  nothing 
more  nor  less  than  Land  Scue\'y."* 

Land  scurvy  is  admitted  to  exist  by  very  high  authority.  Sir 
Gilbert  Blane  observes  :  "  The  scurvy,  a  disease  incident  chiefly  to 
a  sea  hfe,  but  by  no  means  peculiar  to  it,  has  been  nearly  eradi- 
cated by  lemon  juice,  or  more  properly  the  citric  acid  or  the  juice  of 
limes."  ....  The  botanical  genus  citkus  possess  the  same 
Tirtue  and  were  known  two  hundred  j^ears  ago.  "  Scorbutus  or 
scurvy  is  generally  induced  by  a  deficiency  of  fresh  vegetable  food. 
It  is  also  occasionally  referred  to  other  errors  in  diet,  to  the  respi- 
ration of  a  crowded  or  otherwise  impure  atmosphere,  to  excessive 
fatigue,  etc."f  In  Ebekle's  Practice,  page  79,  is  stated  as  follows: 
"At  present,  however,  the  term  (that  is,  scorbutus)  is  properly 
restricted  to  a  peculiar  form  of  the  disease,  which  is  undoubtedly 
connected  with  a  morbid  condition  of  the  blood,  arising  from  a 
want  of  proper  nourishment,  or  other  causes  tending  to  derange 
the  assimilating  functions.  This  affection  seldom  occvirs  in  its 
most  aggravated  form  excej)t  among  seamen;  although  slight,  and 
occasionally  even  very  severe  cases  are  met  with  in  individuals 
deprived  of  wholesome  nourishment  and  a  pure  air,  who  have 
always  resided  on  shore."  Now,  what  can  be  expected  of  large 
families  domiciled  in  our  large  cities,  in  crowded  tenement  houses, 

*  M.  L.  Knapp,  M.D.,  "  Inquiring  into  the  Nature  of  the  Nursing  Sore  Mouth 
Affection,"  page  189. 
I  Marshall  Hall,  Principles  of  the  Theory  and  Practice  of  Medicine,  page  383, 


270  Orthop^bia. 

witli  their  limited  means  of  providing  wholesome  nourishment  and 
pure  air.  Can  parents  thus  circumstanced  have  healthy  children  ? 
Will  they  not  partake  of  the  infirmities  of  their  j)arents,  or  will 
not  a  scorbutic  diathesis  be  induced  from  these  unfavorable  cir- 
cumstances ? 

Hence  it  is,  as  I  have  stated,  that  more  than  the  majority  of  our 
patients  laboring  under  synovitic  invasions  have  a  scorbutic 
diathesis,  proven  by  their  greater  susceptibility  of  cure,  than  those 
laboring  under  strumous  constitutions,  where  we  have  the 
glandular,  parenchyma  and  cancellated  tissues  so  impaired.  In 
scorbutus  it  is  functional  morbid  secretion,  impairing  serous, 
mucous  and  cellular  tissues,  which  are  relieved  by  proper  alimen- 
tation and  favorable  hygiene,  which  the  order  and  favorable  con- 
struction of  the  Hospital  for  the  Relief  of  the  Ruptured  and  Crippled 
affords.  The  ventilation  of  the  hospital  is  as  nearly  perfect  as  pos- 
sible. Seventy-five  per  centum  of  the  crippled  children  treated  in, 
this  institution  are  restored  to  an  ability  to  labor  for  their  future 
suj)port;the  treatment  is  strictly  conservative  and  expectant,  and  of 
three  hundred  and  sixty  in-patients  treated  annually  there  never 
exceeded  twelve  deaths  diudng  the  past  twenty  years. 

The  strumous  diathesis  can  be  most  fully  presented  in  the 
following  case :  Nelson  Pacey,  aged  four  years,  was  admitted  to  the 
Hospital  for  the  Relief  of  the  Ruptured  and  Crippled,  March  29th, 
1871,  with  marked  symptoms  of  Morbus  Coxarius — right  side — of 
one  year's  standing,  dating  fi'om  a  fall  at  that  time,  though  nO' 
symptoms  supervened  during  six  months  after  the  fall.  Famil}'^ 
history  indefinite,  though  evidently  presenting  a  strumous  diathesis. 
Treatment,  a  Spanish  fly  blister  apphed  for  eight  hours,  and  then 
poulticing  for  thirty-six  hours.  After  healing,  an  anodyne  liniment,, 
consisting  of  compound  soap  liniment  containing  solution  of  iodine 
and  belladonna,  cotton  batting  and  the  roller  firmly  applied,  and 
reapplied  night  and  morning.  An  alterative  tonic,  consisting  of 
compound  tincture  of  bark,  six  ounces,  and  two  gTains  of  bichloride 
of  mercury,  a  teaspoonful  twice  a  day;  also  cod  liver  oil  at  intervals. 
Under  the  very  favorable  hygiene  of  the  house,  at  the  termination 
of  six  months  not  the  slightest  indication  of  the  disease  could  be 
detected.  There  had  not  been  an  interim  of  unfavorable  symptom,, 
the  boy  enjoying  apparently  good  health  up  to  October,  1874.  He 
then  complained,  and  on  examination,  hypersemia  of  the  glands  in 
the  inferior  maxillary  region  was  detected.  Large  doses  of  the 
syrup  of  iodide  of  iron,  and  topical  application  of  iodine  preparation. 


PLATE   IV 


SACKjn  7/iLH[LKS5>  ein:i  is-bi  tost  a '..'i 


Normal  condih'on  oF  sound  side. 


Etiology  of  Constitutional  Byscrasia.  271 

afforded  no  relief ;  the  disease  advanced  upon  a  decline  of  appetite. 
On  January  2d,  1875,  he  complained  of  severe  pain  in  the  formerly 
diseased  hip.  The  ordinary  treatment  afforded  no  relief,  and  he 
died  on  February  28th.  An  autopsy  was  made  twenty-four  hours 
after  death.  The  general  appearance  was  a  slight  yellow  tinge 
about  the  face  and  abdomen.  Internally  were  found  slight  pleuritic 
adhesions  of  right  side;  thoracic  viscera  normal;  a  lai'ge  quantity  of 
a  3^elIowish  jelly-like  fluid  in  the  peritoneal  cavity;  liver  about  one- 
fourth  larger  than  normal,  left  lobe  elongated.  On  surface  and  on 
section  numerous  millet  seed  whitish  formations;  some  in  the  spleen; 
kidneys  normal.  No  tubercles  found  in  any  of  the  serous  cavities. 
In  gastro-hepatic  region  a  large  gland  (the  size  of  an  egg)  lay 
pressing  against  the  ductus  communis  choledicus,  pyloric  orifice  of 
stomach  and  receptaculum  chyli.  Mesenteric  glands  all  enlarged, 
stomach  and  intestines  ordinary.  Cervical  glands,  right  side,  varied 
in  size  to  that  of  a  pigeon's  egg.  The  gland  to  the  right  of  the 
thyroid  cartilage  had  separated  the  internal  jugular  vein  from  the 
carotid  artery  one  inch  and  pressed  against  pneumogastric  nerve. 
Glands  presented  hyperplastic  formation  with  caseous  and  fibrous 
material  interspersed.  Examination  of  diseased  hip: — Eight  cap- 
sular-ligament  found  intact ;  no  fluid  within  the  capsule  ;  ligamentum 
teres  detached  easily;  suction  force  normal;  head  of  the  femur 
flattened  from  absorjDtion  of  cartilage  and  devoid  of  pearly  whiteness. 
Hollow  groove  around  border  of  ej)i]Dhyscal  attachment  and  also 
from  ligamentum  teres  to  transverse  groove.  Microscopical 
examination  showed  fatty  changes  in  bone  corpuscles  nearest 
cartilage.  Autopsy  made  by  Professor  Edward  G.  Janeway,  M,  D., 
Pathologist  to  the  Hospital  for  the  Eelief  of  the  Kuptured  and 
Crippled,  and  notes  taken  by  my  senior  assistant,  V.  P.  Gibney, 
M.D.  The  following  engi-aving  represents  the  vertical  section  of 
the  head  of  the  diseased  bone  and  that  of  the  sound  hmb,  and 
beautifully  presents  the  invading  disease  by  yeUow  spots  in  the 
diseased  bone,  the  result  of  tubercle  in  the  cancellated  portion  that 
had  been  kept  dormant  after  the  active  invasion  had  been  subdued 
by  favorable  treatment,  yet  advancing  throughout  the  entii'e 
organization  of  the  parenchyma  and  cancellated  osseous  tissues. 

Struma,  even  under  the  most  favorable  treatment,  can  only  be 
arrested  for  a  time.  Its  most  common  tendency  is  to  invade 
the  system  again,  but  not  always  in  the  first  reHeved  locaUty, 
as  that  of  a  joint.  The  lung,  mesenteric  glands,  or  Uver  may 
follow  on  and  be  relieved  again  for  a  time  only,  but  in  nearly  every 


272  Orthop^bia. 

instance   finally   succumb   to   the    dire    condition   of    the   system 
invaded  with  tubercle. 

In  the  Hospital  for  the  EeHef  of  the  Euj)tured  and  Crippled  a 
careful  record  is  made  of  aU  patients  laboring  under  strumous  or 
scorbutic  dyscrasia,  tending-  to  invasion  of  joints  more  especially  ; 
and  at  the  present  time  over  one  hundi-ed  and  seventy  patients  a 
day  are  under  medical  observation  and  treatment  in  the  in-door 
department,  and  one  hundred  and  over  of  disjoensary  patients. 

The  following  is  an  equally  interesting  case,  being  that  of  one 
of  compression  of  the  spinal  cord  in  Potts'  Disease,  from  induration 
and  absorption  of  the  cancellated  bodies  of  the  vertebrae. 

Albert  S ■  was  admitted  to  the  Hospital  for  the  Relief  of  the 

Ruptured  and  Cripi^led  at  six  years  of  age,  suffering  from  caries  of 
the  dorsal  vertebrae  with  paraplegia. 

The  httle  j^atient  had  never  enjoyed  good  health,  and  at  the  age 
of  four  and  a  half  years  a  small  knuckle  was  first  observed  on  the 
back. 

At  the  date  of  his  admission  he  was  ansemic,  poorly  nourished, 
and  there  was  found  quite  a  prominence  at  the  eighth  dorsal 
vertebra,  with  considerable  tenderness  on  pressure  over  this  region 
of  the  spine.  The  child  was  totally  unable  to  walk,  or  even  to  stand 
alone  without  assistance,  and  along  with  the  paraplegia  there  was 
a  tremor  of  the  limbs.  There  was  also  incontinence  of  uiine  and 
partial  paralysis  of  the  sphincter  ani.  The  anterior  portion  of  the 
chest  was  protruded,  giving  a  pigeon-breast  deformity.  No  sign 
of  any  abscess  was  jDresent.  A  spinal  brace,  provided  with  a  head- 
spring to  support  the  weight  of  the  head,  was  carefully  fitted  to 
his  back  (see  Fig.  81,  page  196),  cod  liver  oil  and  an  alterative 
tonic  were  ordered  for  him,  and  it  was  attempted  by  means  of  a 
good,  nourishing  diet  to  improve  his  general  health  as  much  as 
possible. 

About  six  months  after  his  admission  to  the  hospital  some  very 
troublesome  bed-sores,  with  extensive  sloughing  of  the  tissues,  made 
their  appearance.  These  resisted  the  most  persevering  efforts  to 
cause  them  to  heal,  and  although  there  were  evidences  of  improve- 
ment in  their  condition  at  times,  they  continued  to  extend,  and  be- 
came such  a  drain  upon  the  system  that  it  became  manifest  that  the 
case  was  a  hopeless  one. 

An  obstinate  diarrhoea  was  also  a  soui'ce  of  much  annoyance  and 
a  cause  of  considerable  loss  of  vital  power,  but  this  was  finally  con- 
trolled by  large  doses  of  camphor  and  laudanum. 


PLATE  V 


SACKETI  S'UHELMSI.  BErZIG  45-51  ROSCST.N.V 


Spinal    Caries  resuit-ing  in  paraplegia 


Etiology  of  Constitutional  Dyscrasia.  273 

"When  he  had  been  in  the  hospital  one  year  pneumonia  made  its 
appearance,  and  in  the  aheady  weakened  condition  of  the  patient 
it  was  impossible  for  him  to  survive  this  severe  complication,  and 
he  died  two  and  a  half  years  after  the  first  appearance  of  the  spinal 
disease. 

At  the  autopsy,  which  was  conducted  by  Prof.  E.  G.  Janeway, 
M.D.,  the  pathologist  of  the  hospital,  the  body  was  found  to  be 
extremely  emaciated,  with  large  bed-sores  over  each  hip,  extending 
to  the  trochanters.  There  was  a  marked  spinal  curvature,  embrac- 
ing the  whole  dorsal  region  of  the  column,  with  its  summit  at  the 
sixth,  seventh  and  eighth  vertebrae. 

On  examining  the  spinal  column  anteriorly  there  was  found  ex- 
tending one  inch  to  either  side,  and  two  inches  in  length,  a  sac 
containing  cheesy  matter.  The  walls  of  this  sac  were  formed  by 
the  anterior  common  ligament,  thickened  connective  tissue  and  the 
pleura. 

A  vertical  section  of  the  column  from  before  backward  showed 
the  body  of  the  eighth  dorsal  vertebra  to  be  almost  entirely  gone, 
and  the  sixth,  seventh  and  ninth  largely  involved.  In  j)lace  of  the 
eighth  dorsal  vertebra  there  was  a  quantity  of  pultaceous,  curdy 
matter  pressing  upon  the  spinal  cord  (see  colored  engraving).  The 
cord  itself  at  the  locaUty  of  the  seventh  and  eighth  dorsal  vertebrse 
was  anaemic,  without  apparent  blood  vessels,  yellowish  and  small 
in  size,  probably  due  to  fatty  change  in  the  nerve  cells. 

This  case  is  of  extraordinary  character,  and  it  is  but  seldom  that 
an  autopsy  is  attainable. 

My  senior  assistant,  Virgil  P.  Gibney,  M.D.,  and  J.  W.  Cren- 
shaw, M.D.,  and  E.  F.  Horst,  M.D.,  two  of  my  junior  assistants, 
tabulated  from  our  records  5,461  cases  as  diagnosed  and  subse- 
quently treated,  verifying  the  condition  of  the  patients. 

The  tables  are  as  follows  : 

Table  I. 

Caries  of  the  vertebrae,  males,. . . .   1,329,  54  per  cent. 

Hip  disease,  "      ....       909,  50 

Synovitis  of  the  joints,       "      ...       670,  56J       " 

Caries  of  the  vertebrae,  females,  . .    1,126,  46         " 

Hip  disease,  "  . .       909,  50 

Synovitis  ofthejointsoflimbs,  females,  518,  43^       " 


274 


Orthop^dia. 

Table  II. 


Showing  the  relative  ages  of  the  5,461  cases  of  joint  disease,  1864 
to  1877. 

Caries  of  the  vertebrae,  under  14  years  of  age,  2,158,    87|  per  cent. 
Hip  disease,  "       14     "         "        1,602,   88^ 

Synovitis  of  the  joints,    "       14     "         "  851,    71f 

Caries  of  the  vetebrse,  between  14  and  21  yrs.,  180,     71 
Hip  disease,  "         14    "    21    "     168,      9^ 

Synovitis  of  the  joints,      "         14    "    21    "     125,    lOf 

Caries  of  the  vertebrae,  over  21  years 117,     4^ 

Hip  disease,  "    21     "     48,     2i 

Synovitis  of  the  joints,      "     21      "     212,    17^ 


Table  III. 

Showing  the  relative  ages  of  860  cases  of 
Caries  of  the  vertebrae,  1  year  old, 
Hip  disease  1     "        " 

Synovitis  of  knee,  1     "        " 

"  ankle,  1  " 
"  elbow,  1  " 
"  shoulder,  1  " 
"  wrist,  1  " 
Caries  of  the  vetebrae,  4  years  old . 
Hip  disease,  4     "         "  . 

Synovitis  of  knee,  4  "  "  . 
"  ankle,  4  " 
"  elbow,  4  " 
"  shoulder,  4  " 
"  wrist,  4  " 
Caries  of  the  vertebrae,  4  to  14  years. 
Hip  disease,  4   "   14 

Synovitis  of  knee,  4  "  14 
"  ankle,  4  "  14 
"  elbow,  4  "  14 
"  shoulder,  4  "  14 
"  wrist,  4  "  14 
Carries  of  the  vertebrae,  over  14 
Hip  disease,  "   14 


joint  disease  : 

10,  3|  per  cent. 

4,  li       " 

7,  5 

3,  6i       " 

2,  33^      " 

1,  20 


.185, 

.135, 

.   64, 

.  24, 

.     2, 

.     2, 

.     3, 

85, 

215, 

65, 

20, 

2, 

2, 

2, 

16, 

6, 


62:^  per  cent. 

37i  " 

451  " 

50 

33i  " 

40 

60 

28f  per  cent. 

591  " 

461  c. 

411  " 

33i  " 

40 

40 

n  " 


Etiology  of  Constitutional  Dyscrasia. 


275 


Synovitis   of  knee,         over  14  years,    4,   2f  per  cent. 
"   ankle,            "    14       "  1,     2 

"   elbow,  "   14       "        —    — 

"   shoulder,      "    14       " 

"   wrist,  "   14       " 


Table  IV. 
Showing  diseases  of  childhood  tending  to  joint-diseases : 


i 

> 

u 

Oi 

'i 

c3 

a 
1 

5 

■-3 

2 

's 

0 

0 
s 

0 

> 

fin 

=1 
Pi 

o3 
GQ 

03 

5 

o 

e3 

5^ 

03 

S 

0 

.a 

>> 

H 

^ 

^ 

Spine                  

15 

18 

4 

5 

4 

3 

1 

1 
1 

1 

I 

1 

Hip  

1 

Knee 

4 

1 

4 

Ankle 

1 

1 

, 

2 

1 

•  * 

27 

25 

17 

5 

4 

3 

3 

3 

3 

2 

1 

Table  V. 


Analyses  of  596  cases 


Number  of  cases. 


Hereditary. 


as  found  in  father. . 
"      "       "  mother. 


"      "       "  both  parents 

"      "      "  other  children  of  family 

"      "       "  both  in  parents  and  children 

Number  analyzed 

Where  cause  was  found  in  acquired  diathesis 

Where  hereditary  and  acquired  diathesis  were  found 


s 

CO 

05 

185 

272 

107 

'  Per 

Per 

Per 

Cent; 

Cent. 

Cent. 

^^H 

60M 

661 

35M 

30f 

24J 

38^4 

29 

29 

31% 

m 

5)^ 

15M 

25M 

24^ 

■16M 

15 

12 

209 

271 

103 

45)^ 

18% 

33 

22K 

10 

18i 

32 


Per 

Cent. 

8U4 
31% 

56% 

31% 

31 

29 

16% 


276  Oethopmbia. 

In  tliese  tables  the  sex  and  age  of  patients  present  interesting 
subject  matter  for  j)athological  consideration.     Of  the  5,461  con- 
rsecutive  cases,  over  seventy-five  per  cent,  were  restored  to  an  ability 
to  labor.     The  treatment  being  conservative  surgery,  based  ujDon 
the   strictest   enforcement   of   favorable   hygiene,    the   ventilation 
being  as  nearly  perfect  as  possible,  the  foul  air  being  drawn  out 
beneath  the  floors  by  means  of  a  heated  stack  or  chimney  four  feet 
in  the  clear  and  ninety  feet  high.    The  entire  sj^ace  under  the  floor- 
ing being  open,  with  a  limited  conduit  of  about  four  feet  entering 
the  stack,  registers  in  the  floors  about  twenty  feet  apart  and  ten 
feet  from  the  outer  walls,  thus  obviating  the  atmosj^heric  influence 
of  cold  walls  which  tend  so  largely  to  hinder  ventilation.     The 
diet  is  largely  milk,  and  carefully  fermented  bread  well  baked  and 
kept  twenty-four  hours  in  a  well  ventilated  room;  beef  and  mutton 
broiled  or  roasted  for  breakfast,  and  bread;  fruit  and   water  for 
luncheon  at  ten  o'clock;  for  dinner,  in  addition  to  meat,  potatoes, 
turnips  or  other  vegetables,  milk,  including  the  cream,  at  morning 
and  evening  meals.     Water  limited  to  the  hours  of  luncheon,  dinner, 
and  at  three  o'clock  in  the  afternoon,  exception  being  made  in  cases 
when  an  extraordinary  condition  of  the  patient  presents,  requiring 
a  special  dietary.     All  food  is  partaken  of  at  stated  periods.     No 
child,  able  to  hold  up  its  head,  is  ever  kept  in  bed  during  the  day, 
and  all  able  to  walk  by  pushing  a  chair  before  them,  have  to  thus 
exercise  for  a  certain  time,  which  is  determined  by  their  strength 
and  freedom  from  pain;  and  those  unable  to  walk  from  pain  and 
tenderness,   are    supi^lied  with   rolling  chaii's,  which  afford  them 
exercise  and  comfort  in  associating  with  the  active  patients.     No 
extension  of  spine  or  limbs,  by  means  of  weights  and  pulleys,  or 
plaster  encasement  of  the   spine  or  limbs.     The  diseased  spine  or 
limbs  are  supported  by  steel  frames    and  bandages,  the  hip  and 
other  joints  being  covered  carefully  night  and  morning  with  cotton 
batting,  retained  in  place  by  the  roller  bandage  firmly  di-awn  over 
the  pelvis  and  upper  third  of  the  thigh  in  cases  of  hip  disease.     In 
ordinary  cases  of  painful  joints,  hot  water  applied,  has  often  afforded 
much  reUef ;  in  other  cases  cold  water,  when  hot  water  has  failed, 
or  ice,  has  served  a  good  purpose.     Therapeutic  agents  are  exceed- 
ingly limited.     The  compound  tincture  of  bark,  to  six  ounces  of 
-which  are  added  two  grains  of  the  bichloride  of  mercury,  tincture 
of  the  chloride  of  iron,  and,  in  extreme  physical  depression,  stimu- 
lant tonics,  without  regard  to  inflammation  or  fever,  milk  punch  and 
bread  mucilage  and  raw  beef  sandwiches,  cod  liver  oil  and  the 


Etiology  of  Constitutional  Dyscbasia.  277 

syrup  of  the  iodide  of  iron.     In  rachitic  cases,  the  subnitrate  of 

bismuth,  and  over  the  abdomen  an  inunction  of  cod  liver  oil the 

skin  bein^  thoroughly  cleansed  with  warm  vrater  and  soap  before 
reapplying — and  when  the  oil  can  be  taken  in  the  stomach,  from  two 
to  three  teaspoonfuls  a  day  is  given. 

In  the  acute  stage  of  disease  vesications  are  employed,  and 
poulticing  for  thirty-six  hours  after,  producing  a  derivative  effect 
much  superior  to  that  of  leeching  or  cupping — this  treatment  being 
renewed  until  pain  ceases.  The  hniment  used  is  the  compound- 
soap  liniment,  with  the  fluid  extract  of  belladonna  and  compound 
solution  of  iodine;  carbolic  acid  and  water  for  the  cleansing  of 
abscesses  and  idcers.  Galvanic,  Faradic  and  Static  electricity  are 
made  available,  and  from  these  agents  are  obtained  most  valuable 
results. 

During  the  summer  months,  when  the  weather  is  favorable,  oj)en 
air  excursions  are  frequently  made  to  the  sea  side.  Here  the 
patients  spend  an  entire  day  and  are  permitted  to  bathe  in  the  surf 
and  enjoy  the  fresh  sea  air. 

These  therapeutic  and  hygienic  measures  constitute  nearly  the 
entire  regime  of  the  special  treatment  in  the  Hospital  for  the  Relief 
of  the  Ruptured  and  Crippled,  and  they  have  been  attended  with 
very  favorable  results,  as  before  stated.  Morbus  Coxarius  having 
invited  specialists  to  most  notable  interest,  I  here  present  the  results 
of  treatment  without  extension  from  weights  and  pulleys  or  exten- 
sion splints  of  whatever  form. 

Whole  number  of  cases  treated  from  1863  to  1884 — 2,943;  of  this 
number  724  were  in-patients.  There  were  47  deaths  and  203  in- 
curable. Of  the  whole  number,  2,693  were  reheved.  Thus  seven 
per  cent,  were  incurable,  and  less  than  two  per  cent.  died.  Over 
twenty-one  years  of  age,  102;  from  fourteen  to  twenty-one,  277; 
under  fourteen  years  of  age,  2,564. 

Those  designated  as  relieved,  the  disease  has  been  arrested,  some 
having  been  advanced  to  the  second  and  third  stage  when  received 
for  treatment,  and  of  the  latter  many  restored  to  limited  movement 
of  the  hip-joint  and  the  limb  not  shortened  two  inches,  others  to 
normal  condition. 


CHAPTER    XII. 

PATHOLOGICAL  CONSIDERATION  OF  DISEASES  OP  THE  JOINTS. 

Abnormal  functional  nervous  energy  tends  to  degeneration  of  tissues. — 
Acute  and  chronic  inflammation  of  the  joints. — Not  a  local  impression,  but 
always  attended  with  febrile  symptoms. —  Richet's  experiments. —  Synovitis.— 
Case  recited  by  Dr.  Stanley,  of  St.  Batholomew's  Hospital. —  Dr.  Holmea 
Coote's  description  of  a  case  of  synovitis. —  Dr.  Edward  Rindfleisch  and  Dr.  R. 
Volckmann  on  the  progressive  stages  of  synovitis. —  Morbus  cosarius. —  Acute 
and  chronic  forms.  Mrst  stage :  Its  diagnosis  and  treatment. —  Dr.  William 
Coulson  on  scorbutic  diathesis. —  Shortening  of  the  diseased  limb.  Second 
stage  :  Extension  by  weight  and  pulley  will  not  prevent  shortening  of  limb. — 
Result  of  experience  in  859  cases  of  hip  disease. —  Treatment  as  pursued  in 
the  Institution  for  the  Ralief  of  the  Ruptured  and  Crippled. —  Hospital  for  sick 
children  in  London. —  Cure  reported  by  Mr.  Thomas  Holmes.  Third  stage : 
Illustrative  cases. —  Tabulated  statement  of  results  of  operation. —  Mr.  Holmes' 
analysis  of  the  treatment  at  Sick  Children's  Hospital. —  Excision  of  the  hip. — 
Barwell  ou  diseases  of  the  joints. —  Returns  from  Charing  Cross  Hospital, 
London. —  Treatment. —  Dr.  William  Coulson,  surgeon  to  the  Magdalen  Hos- 
pital, London,  on  the  pathological  condition  of  patients  suffering  from  this 
class  of  ailments. —  The  beneficial  effects  of  moderate  exercise. —  Torpidity  of 
the  digestive  processes. —  Treatment  in  special  cases. —  Extension  apparatus, 

—  Pathology  of  hip  disease   summarized.  —  Prognosis    of   unfavorable  cases. 

—  Character  of  the  secretioia. —  Treatment  when  unfavorable  symptoms  occur 
after  excessive  spontaneous  discharge. — ^  Number  of  cases  of  morbus  coxarius, 
caries  of  the  spine  and  synovitis,  treated  at  Hospital  for  the  Relief  of  the 
Ruptured  and  Crippled  during  last  nine  years. — •  Pyemic  'Dyscrasia  of  the  vital 
functions  a  condition  consequent  upon  complicated  pathological  invasions. — 
The  regime  imperatively  necessary  to  be  even  partially  successful  in  this  hap- 
less condition. —  Diet. —  Neuralgia  of  the  diseased  parts  a  frequent  resultant 
of  treatment. —  Remedy. —  Local  treatment  of  sloughs. —  Mr.  Holmes  Coote's 
opinion  of  the  treatment  to  be  pursued. —  Several  ailments  that  assimilate  hip 
disease. —  Mr.  Erichsen  on  chronic  rheumatic  arthritis. —  Neuralgia  of  the 
sacro-iliac  joint. —  Coxalgia. 


Aberrations  of  nutrition  tending  to  changes  in  the  alimentary 
materials  for  organized  tissues  must  result  in  an  anomalous  order 
of  development.       Normal    maintenance  is   dependent   upon   due 


Diseases  of  the  Joints.  279 

functional  activity  in  the  absorption  of  alimentary  material,  cir- 
culation, respiration  and  excretion ;  and  each  of  those  functions 
dependent  iipon  nervous  energy.  This  is  most  readily  observed  in 
a  deficiency  of  nerve  power  in  a  limb,  or  the  retarded  convalescence 
of  a  patient. 

These  considerations  are  of  the  utmost  importance  in  the  diag- 
nosis of  any  apparent  local  disease,  and  not  in  the  selection  of 
specifics  for  its  cure. 

Abiii  rmal,  functional,  nervous  energy  tends  to  degeneration  of 
tissues,  with  an  increasing  tendency  to  local  impairment  of  parts  — 
such  as  that  of  the  joints,  and  not  merely  the  sequence  of  inflam- 
mation, the  result  of  congestion,  as  formerly  considered.  In- 
flammation exists  and  is  still  continued  from  deficiency  of  nutrition 
and  perversion  of  secretion  in  the  parts  presenting  the  following 
conditions : 

Inflammation  of  the  surrounding  tissues  —  acute  and  chronic  — 
extending  to  the  cancellous  tissues  of  the  bone.  Secondary  effects, 
suppuration,  necrosis,  ulceration  of  the  articular  cartilages,  elonga- 
tion of  ligaments  and  subluxation,  as  in  that  of  the  knee;  and 
complete  luxation  in  others,  as  in  that  of  the  hip. 

Inflammation  of  a  joint  is  not  strictly  a  local  impression,  although 
induced  by  external  injury;  as  from  a  blow,  wound,  or  exposure  to 
cold.  It  is  invariably  attended  by  febrile  symptoms,  and,  in  severe 
cases,  involves  the  heart  and  pericardium.  The  surroundings  of 
the  joint  become  swelled,  and  the  limb  assumes  a  semi-flexed  posi- 
tion ;  tending  to  relief  from  pain  by  the  relaxing  of  the  lateral  and 
other  ligaments  relieving  pressure  on  the  inflamed  tissues.  Of  the 
actual  condition  of,  the  joints  we  have  but  a  limited  knowledge, 
because  of  the  want  of  observation  not  readily  attained  by  dissec- 
tions made  upon  human  joints  at  this  stage  of  the  invasion. 
Eichet  experimented  upon  animals  by  injecting  irritating  fluids 
into  their  articulations.  The  first  effect  was  a  distension  of  the  peri- 
pheral blood  vessels,  a  disappearance  of  the  epithelial  covering,  a 
dull  appearance  of  the  synovial  membrane,  having  an  uneven, 
granular  roughness  of  elevated,  small  processes  —  the  enlarged 
papillae  of  the  synovial  membrane.  This  vascular  injection  ter- 
minated at  the  border  of  the  articular  cartilages,  for  a  time,  and 
then  extended  to  the  surface;  presenting  there  a  bright  vascular 
zone.  This  vascular  zone  gradually  increased  and  extended  upon 
the  cartilage  to  the  degree  of  congestion  and  the  farther  enlarge- 


280  Obthof^edia. 

ment  of  the  papillas.  Fibrine,  then,  was  effused  on  the  inner  sur- 
face of  the  synovial  membrane,  tending  to  an  increase  of  thickness ; 
being  of  a  thick,  viscid  consistence.  It  finally  became  turbid,  and 
mixed  with  reddish  serum  and  oil  globules. 

In  man,  this  conditiou  of  synovitis  is  of  fearful  import,  as  it 
advances  rapidly  to  the  destruction  of  all  of  the  implicated  tissues. 
The  synovial  secretion  increases  largely,  and  where  opportunity  has 
been  afforded  for  microscopic  examination,  pus  corpuscles  have 
been  found  in  great  numbers.  The  synovial  membrane  having  be- 
come soft  and  swollen,  with  great  distention  of  the  joint,  inducing 
the  most  excruciating  pain,  and  compelling,  as  it  were,  the  opening 
of  the  distended  parts  —  a  procedure  attended  with  almost  a  cer- 
tainty of  the  loss  of  the  limb,  and,  in  many  instances,  of  the  life  of 
the  patient. 

Synovitis  most  commonly  presents  in  a  less  violent  form,  and  in 
young  subjects.  Even  the  acute  condition  subsides,  in  some  sub- 
jects to  a  sub-acute,  and,  finally,  chronic  form.  The  sub-acute 
synovitis  usually  makes  slow  progress,  and  is  attended  with  much 
sensitiveness  when  the  limb  is  moved,  is  greatly  moderated  by  rest, 
and  is  seldom  attended  with  much  constitutional  derangement 
during  the  early  progress  of  the  ailment. 

If  not  arrested,  a  recurrence  of  symptoms  ensues  with  an  increase 
of  effusion  and  a  softening  of  the  ligaments  and  serious  impair- 
ment of  the  articular  cavity,  with  increasing  distension  about  the 
joint.  We  then  have  Hydrops  Ai^ticuU,  and  a  chronic  condition 
established.  The  hip,  knee,  elbow  and  ankle  are  all  subject  to  this 
pathological  condition ;  greatly  distorting  the  parts  affected  from 
the  irregular  extension  of  the  ligaments  and  unequal  distension 
from  effusion,  even  to  the  extent  of  subluxation  of  the  joint.  We 
are  informed  by  such  indubitable  authority  as  that  of  Mr.  Stanley, 
who  had  the  specimen  preserved  in  St.  Bartholomew's  Hospital,  of 
a  case  of  dislocation  of  the  head  of  the  femur  upon  the  dorsum  illii 
from  excessive  distension  from  fluid.  The  capsule  was  entire,  and 
measured  five  inches,  in  one  direction.  The  cavity  of  the  acetabu- 
lum had  almost  disappeared  ;  being  both  reduced  in  size  and  filled 
by  fibrous  tissue. 

In  synovitis  of  the  knee,  in  its  early  stage,  a  peculiar  grating  sen- 
sation is  perceptible  when  pressing  and  moving  the  patella.  This 
arises  from  an  abnormal  secretion  upon  the  surface  of  the  cartilagea 
of  the  joint,  and  not  from  a  dryness  of  surface  or  denuded  condition 


Diseases  of  the  Joints.  281 

of  the  joints.  The  synovial  membrane,  after  several  months  dura- 
tion of  inflammation,  becomes  greatly  thickened,  and  the  joint  sub- 
ject to  an  attack  of  pain  after  undue  exercise  or  exposure  to  cold. 
Otherwise,  the  condition  may  be  quite  endurable,  and  tends,  ap- 
parently, to  an  arrest  of  the  ailment.  This  progressive  condition, 
if  not  arrested,  results  in  an  effusion  of  lymph  and  fibrin  within 
the  synovial  membrane ;  becoming  greatly  organized,  and  terminat- 
ing in  contracting  adhesions.  This,  again,  has  its  reparative  tend- 
ency ;  in  covering  roughened  bone  or  indurated  cartilage  on  the 
articular  extremity.  If  this  favoi'able  condition  fails  to  ensue,  a 
chronic  condition  becomes  established.  The  synovial  membrane  is 
then  involved  to  the  ulceration  and  absorption  of  the  cartilages,  begin- 
ning at  their  edge  and  gradually  extending  until  the  denuded  surfaces 
of  the  bones  are  exposed.  The  joint,  when  in  this  condition,  usually 
contains  a  yellow  fluid,  in  which  floats  flakes  of  lymph  and  pus, 
that  is  eventually  discharged  externally  from  draining  sinuses. 
Various  morbid  changes  then  follow,  such  as  infiltration  and  thick- 
ening of  the  surrounding  tissues,  which,  in  some  cases,  become 
filled  with  thick  lardaceous  deposits,  softening  and  disorganizing 
the  different  tissues.  In  this  condition  the  joints  become  distorted  — 
tending  to  a  subluxation  —  and  the  surrounding  integument  ad- 
herent. 

Mr.  Holmes  Coote,  in  his  '•'  Treatise  on  Joint  Disease,"  describes 
a  dissection  he  made  of  a  joint  in  this  diseased  condition : 

"In  a  case  examined  by  me,  December  3,  1846,  for  the  late  Mr. 
Stanley,  the  encroachment  of  the  synovial  membrane  upon  the 
cartilage  was  considerable;  the  cartilage  itself  Avas  loosened  from 
the  bone,  which  was  more  vascular  than  natural,  but  of  usual  firm- 
ness. Several  of  the  glands  in  the  popliteal  space  had  undergone 
the  same  degeneration.  I  could  strip  off  some  of  the  pulpy  mass, 
covered  by  epithelium,  from  the  vascular  layers  of  the  synovial 
membrane  on  which  it  lay.  The  surrounding  vessels,  in  these  cases, 
become  the  seat  of  very  active  circulation." 

Prom  this  we  learn  what  an  extent  of  induration  a  very  slight 
cause  may  induce  under  a  peculiar  constitutional  condition,  tending 
to  this  result.  Such  cause  may  be  a  slight  bruise,  being  then 
strictly  local,  and,  under  a  normal  condition  of  the  system,  repara- 
tive force  would  most  readily  remove  the  cause  of  irritation.  Dr 
Edward  Eindfleisch,  in  his  commendable  work  on  Pathological 
Histology,  remarks  :     Since  Von  Eecklinghausen  found  reabsorb- 


282  Orthopjedia. 

ing  stigmata  of  the  lymphatic  vessels  upon  the  serous  cavity  of  the 
diaphragm,  we  may  even  advance  to  the  opinion  that  the  fluid  in 
the  interior  of  a  serous  cavity  is  subjected  to  a  certain  renewal —  a 
change.  So  much  the  more  rapidly  will  also  an  irritating  body 
from  the  liquor  sanguinis  appear  in  the  serous  cavity.  Here,  how- 
ever, as  in  the  joints  and  endocardium,  there  is  yet  added  to  the  — 
shall  we  say  fermentative  ?  —  irritants  from  the  infecting  body,  a 
second  auxiliary  force  :  the  movement  of  the  opposing  layers  of  the 
serous  sac  against  each  other.  In  virtue  of  this  friction,  the  one 
layer  rubs  the  infectious  body  straightway  into  the  other,  and  I 
have  no  hesitation  in  perceiving  an  auxiliary  force  for  the  develop- 
ment of  the  inflammation.  The  recuperative  force  only  exists  in 
the  healthy  conditioned  individual,  and  is  of  wonderful  efficacy  in 
cases  of  great  injury  done  the  tissues.  Morbid  conditions  must 
follow  disorganization  from  violence  done  tissues,  tending  to  irritat- 
ing secretions  that  will  be  thrown  into  serous  cavities ;  and  as  Von 
Eecklinghausen  discovered  reabsorbing  stigmata  of  the  lymphatic 
vessels  upon  the  serous  cavity,  in  healthy  subjects  it  will  be  reab- 
sorbed, but  in  enfeebled  subjects,  from  the  want  of  active  assimila- 
tion and  elaboration  of  nutrition,  the  reabsorbing  stigmata  are  not 
found,  and  the  irritating  secretion  remains,  and,  as  a  ferment  in- 
creases, producing  the  anomalous  condition  of  joint  described  by 
Mr.  Coote. 

E.  Volkman  informs  us  that  in  the  forming  stage  of  synovitis  we 
have  first  an  acute  purulent  catarrh,  —  a  blennorrhoea  of  the  joint. 
The  normal  epithelial  cells  are  cast  ofE  the  stratum  of  connective 
tissue,  without  the  continuity  of  the  surface  being  disturbed,  pro- 
ducing large  amounts  of  pus  corpuscles  which  cloud  the  originally 
clear  contents  of  the  articular  cavity  and  convert  it,  the  longer  it 
continues,  more  into  a  thickish  pus,  drawing  out  into  threads 
because  mixed  with  synovia.  In  the  further  cause,  a  turn  for  the 
worse  sets  in,  especially  by  this,  that  the  articular  cartilage  is  irri- 
tated by  the  stagnant  pus,  thereby  undergoing  a  kind  of  decomposi- 
tion, and  is  excited  to  a  kind  of  superficial  ulceration  which  destroys 
the  cartilage,  layer  by  layer,  and  after  this,  may  pass  over  to  the 
bone  itself.  In  this  case  the  cartilage  perishes  by  a  process  which 
begins  with  cellular  division  and  ends  with  the  complete  dissolution 
of  the  cells  as  also  of  the  inter-cellular  substance.  If  we  make  a 
vertical  section  through  the  cartilage  we  discover  the  first  layer  and 
cellular  divisions,  perhaps,  in  the  tenth  to  the  twelfth  layer,  counting 


Diseases  of  the  Joints.  283 

from  above.  These,  primarily,  go  the  way  of  simple  hyperplasia 
of  cartilage ;  we  see  groups  of  four  to  ten  cells,  which  yet  distinctly 
bear  the  character  of  cartilage  cells,  in  a  common  capsule.  Farther 
toward  the  surface,  the  ordinary  pus  corpuscle  takes  the  place  of 
the  cartilage  cells,  together  with  very  considerable  dilatation  of  the 
cartilage  cavities,  and  the  capsules  gradually  become  indistinct. 
The  basis  substance  has,  meanwhile  become  finely  granular,  cloudy; 
toward  the  surface  it  more  and  more  disappears,  and,  finally,  liquefies 
in  the  contents  of  the  articular  cavity.  Simultaneously  with  this 
complete  liquefaction  of  the  basis  substance  is  produced  the  open- 
ing of  the  most  superficial  of  the  cartilage  cavities.  The  pus  cor- 
puscles which  have  mostly  been  converted  by  retrogrenine  meta- 
morphosis into  fatty  or  fatty  granular  detritus,  mingle  with  the 
pus  in  the  articular  cavity ;  a  semi-circular  erosion  of  the  free  edge 
remains  behind  yet  for  a  time,  but  with  it  vanishes  the  last  trace  of 
the  cartilaginous  structure. 

The  suppuration,  however,  like  every  excessive  increase  of  new 
formation,  requires  space  —  under  certain  circumstances,  very  much 
space  —  and  the  mechanical  force  that  is  developed  in  the  con- 
tinued division  and  multiplication  of  cells  is  one  so  considerable 
that  against  it  the  integrity  and  turgidity  of  vessels  cannot 
maintain  themselves  if  both  are  to  exist,  side  by  side,  in  a  given 
space,  and  are  not  capable  of  further  expansion.  In  this  manner, 
by  the  compression  and  rupture  of  vessels,  suppuration  gives  occa- 
sion to  a  series  of  the  most  manifold  and  profound  disturbances 
of  nutrition,  as  far  as  they  affect  the  osseous  tissue,  fall  entirely 
into  the  province  of  necrosis  and  caries. 


MORBUS   COXARIUS. 

Morbus  coxarius  has  its  acute  and  chronic  forms,  and  is  suscepti- 
ble of  being  divided  into  three  distinct  stages.  That  it  occurs  in 
scrofulous  children  not  a  doubt  can  be  entertained ;  but  it  is  often 
observed  in  individuals  who  do  not  present  a  single  indication  of  a 
strumous  diathesis  —  if  we  confine  the  strumous  diathesis  to  tuber- 
culous deposits  involving  the  glandular  and  parenchymal  tissues. 
In  many  patients  laboring  under  morbus  coxarius  the  scorbutic 
diathesis  is  decidedly  indicated  by  spongy  gums,  mouth  bleeding  at 


284  OrthopjEDia. 

night,  and  aphthous  condition  of  the  mucous  membrane  and  no 
enlargement  of  the  glands,  nor  the  most  remote  tendency  to  phthisis 
pulmonalis  in  after-life.  This  condition  may  be  considered  as  the 
"strumous  inflammation  without  tubercle"  of  some  authors. 

First  stage.  —  The  first  indication  of  this  ailment  is  stiffness  of 
the  limb,  most  apparent  after  remaining  quiet  in  a  sitting  posture 
for  some  duration  of  time,  or,  on  leaving  the  bed  in  the  morning. 
After  a  time,  there  is  impediment  in  stooping  and  a  noticeable  pain 
when  drawing  on  the  stocking ;  also,  a  sense  of  fatigue  is  experi- 
enced after  slight  exertion.  Occasional  pains  are  now  felt  down  the 
thigh,  and,  more  especially,  in  the  knee  —  often  exclusively  there ; 
misleading  the  family  practitioner  as  to  the  actual  condition  of  the 
patient.  The  patient  refers  to  the  knee  in  more  than  a  majority  of 
cases,  and  the  knee  is  in  some  instances  found  to  be  swollen  slightly, 
yet  the  seat  of  the  disease  is  in  the  hip. 

Various  opinions  are  advanced  to  account  for  its  occurrence.  By 
some  it  is  believed  that  the  pain  is  conveyed  by  the  branches  of  the 
anterior  crural  nerve  down  the  thigh.  By  others  it  is  asserted  that 
the  obturator  nerve,  in  passing  through  the  thyroid  foramen  is 
affected,  and  in  supplying  the  muscles  of  the  thigh  sends  a  branch 
to  the  inner  side  of  the  knee  where  the  pain  is  most  commonly 
located.  The  pain  is  often  found  along  the  middle  and  on  the 
outer  part  of  the  thigh,  where  the  obturator  nerve  is  distributed 
to  the  muscles  of  the  limb. 

In  the  incipiency  of  this  stage  there  is  no  apparent  indication 
from  superficial  examination  —  taking  a  mere  view  of  the  limb  — 
but  upon  pressing  the  fingers  behind  the  trochanter,  an  elastic  ful- 
ness will  be  detected,  indicating  an  increased  quantity  of  synovial 
fluid  within  the  capsular  ligament,  and  often  tenderness,  —  firm 
pressure  increasing  the  pain  in  the  knee.  The  patient  being  directed 
to  walk,  the  afflicted  limb  will  incline  the  foot  inward  or  outward 
more  than  its  fellow,  and  will  be  restricted  in  movement,  having  a 
stiffened  appearance  while,  in  some  cases,  slight  pain  is  induced 
upon  attempting  to  separate  the  limbs  or  close  them,  laterally.. 
These  are  indications  of  importance  but  commonly  overlooked  by 
the  parents  or  friends  until  actual  limping  is  apparent ;  and  even 
then  they  are  attributed  to  "growing  pains"  or  a  strain  of  the 
joints. 

There  is  no  definite  period  for  this  stage  to  continue;  months, 
and  even  years  may  pass,  the  patient  only  complaining  at  times  and 


Diseases  of  the  Joints. 


285 


mostly  at  night.  It  is  in  the  advancement  of  this  stage  that  there 
is  a  perceptible  change  in  the  contour  of  the  nates.  On  the  affected 
side  a  flattening  and  elongation  will  be  observed,  and  an  increased 
breadth  of  the  lateral  folding  under  of  the  nates.     See  Fig.  106. 

The  foot  of  that  side  will  be  carried  more  directly  Fig.  loe. 

forward  than  its  fellow;  and  in  some  cases  incline 
inward  in  walking. 

The  general  health  in  this  stage  is  usually,  to 
all  appearances,  unaffected;  but  upon  careful 
observation  indications  of  fatigue  upon  slight 
exertion,  an  indisposition  to  join  in  active  sports  — 
probably  because  of  tenderness,  if  not  actual  pain, 
and,  toward  evening,  indications  of  fever  may  be 
observed ;  the  latter  so  slight,  however,  as  to  be 
scarcely  noticed  or  appreciable  by  the  thermometer. 

In  this  stage  the  constitutional  diathesis,  scrofu- 
lous or  scorbutic,  tends  to  a  retarded  or  more  ac- 
tive progress  of  the  ailment.  Scrofulous  subjects 
having  a  tolerable  condition  of  health  will  con- 
tinue in  this  incipient  stage  of  hip  disease  for  a  year  or  eighteen 
months,  as  in  other  scrofulous  diseases.  The  indolent  condition 
renders  the  first  attack  obscure  —  often  without  pain  —  with  inter- 
vals of  apparent  arrest  of  the  disease,  and  after  months  of  advance 
a  diffused  swelling  will  be  observed  about  the  part  affected.  A  slow 
indolent  abscess  forms,  to  the  astonishment  of  the  attendant,  there 
having  been  so  limited  an  expression  of  pain  by  the  patient  com- 
pared to  the  advancement  of  the  disease.  The  child,  probably  of 
rotund  form  and  apparent  good  health,  only  occasionally  complain- 
ing of  pain  in  the  hip  for  a  few  hours  during  the  day,  elicits  no 
special  attention;  but  at  night  its  rest  is  usually  disturbed;  it  will 
scream  out  as  though  frightened  or  in  seeming  agony,  even  bound- 
ing up  in  the  bed,  and  when  spoken  to  will  not  give  a  satisfactory  an- 
swer—  lying  down  again  and  sleeping  quite  composedly,  probably, 
to  again  cry  out  in  a  few  hours  time.  This  is  the  most  decided 
indication  of  the  advancing  hip  disease. 

In  the  scorbutic  diathesis,  or  inflammation  of  the  joints  without 
tuberculous  deposits,  the  constitutional  symptoms  are  much  more 
severe.  Mr.  William  Coulson,  Fellow  of  the  Eoyal  Medico-chirur- 
gical  Society  of  London,  gives  the  following  statement:  "If  the 
complaint  occurs  in   a  scrofulous  subject,  the  inflammatory  action 


286  Orthop^dia. 

will  be  very  much  modified  by  this  state  of  the  constitution.  *  *  ♦ 
Ou  the  contrary,  in  persons  who  are  not  of  a  scrofulous  habit,  the 
local  and  constitutional  symptoms  are  much  more  severe."  *  When 
patients  are  thus  conditioned  they  suffer  intense  pain,  and  the  hip 
is  so  sensitive  that  the  vibration  produced  from  persons  walking 
briskly  over  the  floor  increases  the  morbidly  painful  condition  of 
the  patient.  After  this  painful  condition  has  subsided,  a  limping- 
gait  is  induced,  and  greatly  increased  from  walking  any  considerable 
distance,  and  much  to  their  injury.  When  walking  over  an  irregu- 
lar surface,  they  are  liable  to  fall,  as  the  muscles  of  the  leg  and 
thigh  will  have  lost  some  voluntary  power,  and  have  diminished 
in  size,  very  considerably. 

In  the  cases  of  strumous  diathesis,  if  the  surgeon  makes  pressure 
behind  the  trochanter  major  or  upon  the  psoas  magnus  and  iliacus 
internus,  or  rotates  the  head  of  the  femur  against  the  acetabulum, 
the  patient,  in  most  cases,  will  complain  of  pain,  indicating  the 
seat  of  the  disease,  while  if  much  motion  is  made  it  serves  greatly 
to  aggravate,  and  not  a  doubt  can  be  entertained,  but  that  it 
more  fnlly  establishes  the  disease.  Patients  that  have  been  able  to 
walkabout  with  tolerable  comfort,  after  a  severe  examination  at  the 
hands  of  an  inconsiderate  surgeon,  dates  his  first  confinement  to 
the  house  from  an  inability  to  walk,  because  of  an  increase  of 
pain  and  loss  of  power  in  the  limb,  from  that  time. 

In  cases  of  scorbutic  diathesis  the  severe  pain  and  tenderness 
about  the  hip  and  thigh,  causing  the  patient  to  flex  the  thigh  upon 
the  pelvis  and  rest  on  the  opposite  hip,  determines  the  case  without 
further  examination;  and  yet  these  cases  are  more  promising  of 
cure  than  those  of  torpid  disposition.  The  inflammation  having 
been  subdued  and  the  patient's  general  health  improved,  they  are 
in  many  cases  cured,  perfectly,  in  three  or  four  months;  after  hav- 
ing suffered  for  a  month  from  most  severe  pain,  night  and  day,  and 
requiring  the  constant  attendance  of  nurses  during  that  period  — 
even  opiates  failing  to  afford  relief. 

It  is  in  this  stage  of  the  ailment  that  the  lengthening  of  the 
diseased  limb  is  observed  in  some  patients,  and  from  the  obscurity 
in  which  it  is  involved,  the  cause  has  been  greatly  discussed,  but 
without  arriving  at  any  positive  determination.  The  patient  being 
laid  upon  a  bench  or  table,  because  of  the  firmness  when    thus 

*  Coulson  on  Diseases  of  Hip  Joint :    Lond.  Ed.,  p.  5. 


Diseases  oi  the  Joints.  287 

placed,  and  the  limbs  straightened  as  much  as  possible,  the  troch- 
anter patella  and  malleoli  will  appear  lower  in  the  diseased  than  in 
the  sound  limb.  The  patient  when  attempting  to  walk  extends 
the  sound  limb,  and  is  compelled  to  flex  the  other  by  advancing  the 
knee,  the  foot  being,  most  commonly,  everted.  Some  contend  that 
in  reality  there  is  no  lengthening,  and  others  insist  that  it  is 
actually  longer.  The  opinion  of  those  who  consider  the  limb  to  be 
lengthened  is  that  the  head  of  the  bone  is  enlarged  or  there  is  a 
large  increase  of  synovial  fluid  pressing  the  head  of  the  bone  for- 
ward and  downward ;  while  their  opponents  in  theory,  hold  that 
the  apparent  elongation  is  produced  by  position  of  the  pelvis  — 
being  depressed  upon  the  affected  side.  The  patient  being  disposed 
to  avail  himself  of  the  most  easy  position  relaxes  all  the  muscles  of 
that  side  of  the  body  and  limbs,  and  it  is  not  improbable  that  the 
muscles  of  the  affected  side  have  been  impaired  in  tone,  tending  to 
the  apparent  elongation  of  the  limb  over  which  the  patient  has  no 
control.  This  is  our  opinion  ;  and,  also,  that  the  limb  is,  in  reality, 
not  lengthened,  as  the  patient  when  cured  of  the  disease  in  the 
hip,  has  limbs  of  equal  length. 

The  most  common  condition  of  the  diseased  limb  is  to  find  it 
shortened.  The  muscles  contract  from  irritation  and  the  head  of 
the  bone  is  drawn  firmly  against  the  upper  edge  of  the  acetabulum, 
and  the  knee  slightly  advanced,  is  the  cause  of  shortening.  This 
shortening  in  this  stage  of  the  ailment  never  impedes  motion,  as 
in  the  third  stage.  It  is  in  the  advancement  of  this  stage  that  a 
change  of  position  of  the  trochanter  will  be  observed,  being  ad- 
vanced more  forward,  and  the  nates  of  the  affected  side  flaccid, 
lengthened,  and  flattened.  The  contraction  is  mainly  in  the  front 
of  the  thigh  and  the  limb  somewhat  adducted,  nutrition  being 
partially  impeded,  to  the  lessening  of  the  size  of  the  limb  below 
the  hip,  compared  to  that  of  its  fellow.  The  pain  now  becomes 
more  steady,  and  an  increase  of  temperature  about  the  hip  ensues. 
The  patient  is  at  times  pale  and  then  flushed,  the  skin  being  mostly 
moist,  the  tongue  white,  and  the  strength  declining.  The  pain  at 
the  knee,  which  was  before  intermittent,  now  becomes  steady,  the 
bowels  constipated,  and  the  ailment  passes  into  the  second  stage. 

Second  stage :  The  second  stage  of  the  ailment  is  merely  a  pro- 
longation of  the  symptoms  as  stated,  tending  to  an  apparent  tor- 
pidity of  mental  and  physical  status  of  the  individual,  and  to  the 
increase  of  suffering  in   the  diseased  limb ;  yet,  at  times  there  will 


288 


ORTBOPuEDIA. 


Fig.  107. 


be  an  intermission  of  suffering,  even  to  the  entertaining  of  hopes  of 
recovery;  but  a  powerless  condition  of  the  limb  continues,  and 
more  decidedly  if  the  weight  and  pulley  has  been  applied  early  to 
the  relief  of  pain  :  a  deceptive  hope,  as  the  nerves  of  sensation  have 
been  partially  paralyzed  from  continued  extension,  and  the  disease 
not  arrested.  It  is  in  this  sta2:e  that  the  elons^ated  limb  now  grad- 
ually  shortens  —  in  some  suddenly,  and  to  even  two  or  more  inches  ; 
and  the  patient,  when  in  the  erect  position,  can  only  touch  the 
toes  to  the  floor,  having  a  dispositiou  to  place  the  foot  of  the 
affected  limb  on  the  dorsum  of  the  other  foot  when  standing, 
(see  Fig.  107)  and  even  the  continued  extension  by 
weight  and  pulley  Avill  not  save  the  patient  from  this 
shortening,  as  nothing  is  more  fallacious  than  to  ex- 
pect a  cure  to  be  made  by  a  continued  extension  of 
the  limb,  as  in  that  of  the  weight  and  pulley,  which 
continues  to  extend  to  the  extent  of  yielding,  and, 
physiologically  considered,  to  the  impairment  of  the 
tone  of  the  muscles.  In  our  experience  it  is  only 
palliative  to  pain,  and  not  curative,  but  actually  inju- 
rious as  a  treatment.  This  conclusion  has  been 
arrived  at  from  the  treatment  of  thirteen  hundred  and 
twenty-six  cases  of  hip  disease  in  eleven  years, in  the 
Institution  for  the  Relief  of  the  Ruptured,  and  Crip- 
pled, where  more  than  a  majority  were  cases  that 
had  been  under  treatment  before  being  sent  to  this 
institution,  and  invariably  by  the  weight  and  pulleys; 
the  treatment  having  failed  to  arrest  the  disease  in  its  progress 
or  the  limbs  from  shortening ;  whilst  many  of  the  cases  that 
were  received  in  the  incipient  stage,  and  others  advanced  and 
not  previously  treated  were  more  readily  relieved  than  those  having 
been  treated  by  the  weight  and  pulley.  No  treatment  of  this  kind 
IS  permitted  in  this  institution,  believing  it  to  be  injurious  by  im- 
pairing the  vital  energy  of  the  limbs,  although  an  exceedingly 
popular  remedy.  These  remarks  are  made  from  a  serious  impression 
resulting  from  experience  in  its  not  having  arrested  disease  in  the 
first  stage  of  so  large  a  number  of  cases,  —  convincing  us  most  fully 
that  it  is  not  a  reliable  treatment  under  the  most  favorable  condition 
of  the  patient  —  a  conclusio  i  determined  from  long  experience. 
Therefore  we  feel  justified  m  thus  expressing  our  objections,  but 
with  all  due  deference  to  the  opinion   of  others,  where  they  hare 


Diseases  os  the  Joints.  289 

had  as  extensive  a  practical  experience  in  the  treatment  of  this  class 
of  ailments  as  we  have  had  for  the  past  thirty-five  years.  A  few 
cases  and  an  occasional  success  will  not  determine  the  reliability  of 
any  treatment ;  it  is  only  a  large  experience  with  close  observation 
that  is  to  be  relied  upon. 

It  is  in  this  stage  that  mudi  tumefaction  ensues  ;  or,  in  other 
words,  bursal  developments,  or  abscesses,  as  they  are  commonly 
termed,  are  formed,  which  may  be  dispersed  in  many  instances  by 
elastic  pressure,  and  the  patient  experience  a  perfect  recovery  ;  and 
recovery  may  be  expected  from  the  advanced  conditions  of  the  sev- 
eral stages  of  this  ailment.  The  ligamentum  teres  may  have  dis- 
appeared, and  bands  of  fibrous  tissue  formed  partial  anchylosis,  to 
the  restoration  of  the  limb  to  nearly  a  normal  condition.  We  have 
had  cases  under  treatment  in  which  the  head  of  the  femur  could  be 
dislocated  from  the  articulation  upon  the  dorsum  ilii,  and  there 
distinctly  felt,  and  as  readily  reduced.  And  cases  of  advanced  hip 
disease,  where  from  accident  —  a  fall  on  an  unfavorable  position  of 
the  limb  —  a  dislocation  and  shortening  was  produced,  that  were 
reduced  and  the  patients  fully  restored  to  the  use  of  the  limbs. 

Mr.  Thomas  Holmes  states,  in  his  work  on  the  surgical  treatment 
of  children  (p.  438),  that  a  cure  was  made  under  his  care  at  the 
Hospital  for  Sick  Children,  in  London,  1865.  He  says:  "The 
patient  had  not  suffered  from  any  congenital  affection  of  the  hip. 
There  was  no  formation  of  matter  ;  there  was  no  grating  of  the 
bones  on  each  other.  But  by  a  slight  manipulation  the  head  of  the 
femur  could  be  dislocated  on  to  the  dorsum  ilii,  as  proved  by  the  sen- 
sation of  the  head  slipping  out  of  the  socket,  which  could  be  plainly 
perceived;  and  the  characteristic  shortening  of  the  limb  was  then 
immediately  produced,  and  the  head  could  be  felt  on  the  dorsum 
ilii.  It  was  equally  easy  to  reduce  the  bone  into  its  natural  posi- 
tion." Mr.  Barwell,  in  the  "Diseases  of  the  Joints,"  (p.  297),  says, 
that  "when  the  subsynovial  tissues  in  which  ligaments  are  placed 
inflame,  the  ligaments  themselves  suffer,  softeu  and  become  thick- 
ened or  absorbed,  as  the  case  may  tend."  The  inflammation  having 
subsided  leaves  the  limb  conditioned  as  we  have  described  it,  —  sub- 
ject to  dislocation  from  slight  causes.  This  apparent  laxity  of  the 
surrounding  tissues  of  the  joint  does  not  preclude  the  possibility  of 
recovery,  and  to  a  substantial  condition,  as  we  have  witnessed  in  a 
number  of  cases. 

It  is  in  this  stage  that  the  muscles  become  more  or  less  atrophied, 


290 


Ortitop^dia. 


Fig.  108. 


and  the  breadth  and   flattening  of  the  nates  on  the  diseased  sidf^ 
becomes  more  apparent.     (See  Fig.  108.) 

Some  noted  anthorities  on  this  subject  express  their  opinion  that 
a  failure  in  nutrition  is  the  cause  of  tlie  first  impairment  to  the 
limb,  preceding  even  inflammation  about  the 
joint,  and  hence  the  early  flattening  of  nates  or 
relaxed  condition  of  the  muscles,  tending  to  that 
appearance,  the  thigh  being  flexed  upon  the  pel- 
vis. Abscess  now  presents,  and  most  frequently 
about  the  upper  third  of  the  thigh,  and  upon  the 
outer  border  of  the  rectus  femoris,  commencing 
in  some  cases  much  higlier  but  gradually  gravi- 
tating to  the  lower  position.  After  the  forma- 
tion of  the  abscess  the  patient  is  usually  relieved 
from  pain  and  presents  an  interim,  as  it  were 
from  progress  in  the  ailment  —  a  favorable  ten- 
dency to  an  arrest  of  the  disease ;  many  being 
perfectly  relieved  in  the  second  stage.  The  ab- 
scess, from  persevering  and  judicious  treatment, 
often  entirely  disappears,  and  the  limb  is  restored 
to  a  nearly  normal  condition  of  usefulness  but  not  of  size.  If  not 
arrested  at  this  stage  of  the  ailment  it  portends  an  unfavorable 
prognosis  for  the  future. 

Third  stage :  The  pathological  condition  in  this  stage  of  the  ail- 
ment is  most  unfavorable  to  the  patient ;  caries  of  the  bone  has  now 
ensued  after  a  failure  to  arrest  the  two  previous  stages,  and  Mr. 
Thomas  Holmes  asks  the  question  :  "  Can  any  thing  be  done  to 
rescue  the  child  from  impending  death  ?"  This  must  be  considered 
a  truly  critical  condition  of  the  patient.  This  eminent  authority 
states :  "  If  the  pelvis  is  much  diseased,  if  sinuses  are  numerous  and 
extensive,  and  if  the  internal  organs  (chiefly  the  lungs  and  liver) 
give  clear  symptoms  of  degeneration,  the  result  of  the  disease,  if  left 
to  itself,  will  usually  be  fatal."  And  further :  '•'  I  have  seen  patients 
recover  even  from  such  a  condition  after  excision  of  the  hip. 
Whether  they  would  have  recovered  without  operation  is  more  than 
I  can  say;  but  I  think  not."  *  This  very  candid  writer  impresses 
us  most  unfavorably  in  regard  to  the  results  of  exsection  of  the  hip 
joint,  and  his  conclusions  confined  to  the  third  stage  of  morbus 


T.  Thomas  Holmes,  M.  A.,  Cantab.,  on  "  Diseases  of  Infancy  and  Children.'' 

Lond.,  1868. 


Diseases  of  the  Joints.  291 

coxarius  are  most  reasonably  considered,  tending  to  confirm  our 
objection  to  the  hazardous  treatment  of  the  patient  when  in  this 
extreme   condition.      Mr.  Holmes    claims   to   have   performed  the 
operation  of  exsection  of  the  head  of  the  thigh  bone  more  exten- 
sively than  any  other  surgeon,  and  gives  the  results  of  nineteen 
cases  of  which  he  had  preserved  notes  out  of  a  still  greater  number 
of  cases.     And    it  is  reasonable  to  suppose  them  to  have  been  the 
most  favorably  disposed  cases.     However,  he  premises  his  statement 
of  those  reported  by  stating :  "  The  results  will  always  vary  according 
to  the  kind  of  cases  operated  on.     I  dare  say  this  seems  a  truism,  but 
it  is  at  any  rate,  one  which  is  very  little  dwelt  upon  in  treating  of  the 
subject;  I  mean  this  :  If  a  surgeon  restricts  any  operation,  say  that 
of  an  exsection   of  the  hip,  to  the  best  or  most  curable  cases  of 
confirmed  disease,  he  will  obtain  a  good  percentage  of  success  ;  but 
the   question  will    remain    whether    the  same   success   might  not 
have  been  obtained  by  the  expectant    method.     If,  on    the  other 
hand,  he  restricts  himself  to  cases  in  which,  according  to  all  reason 
able  probability,  spontaneous  cure  is  impossible,  and  operates  upon 
every  case  in  which  the  patient  is  at  all  in  a  condition  to  allow  of 
his  surviving  the  operation,  then   this  tale  of  success  will  be  much 
less ;  but  then,  also,  all  the  successes  must  be  considered  as  clear 
gain."     .     ..."  I  think  a  fair  classification  for  practical  pur- 
poses might  be  made  by  separating  the  deaths  into  those  who  die 
from  the  direct  results  of  the  operation,  and  those  who  sink  from 
constitutional  causes ;  and  the  recoveries  into  those  in  whom  the 
wound  entirely  heals  and  the  limb  is  perfectly  useful ;  those  in  whom 
the  limb  is  useful,  but  the  wound  remains  open  for  an  indefinite 
period  ;  and  those  in  whom  the  patient  recovers,  but  with  a  more  or 
less  useless  limb  and  open  wound  —  in  fact  relapses  into  much  the 
same  state  as  we  usually  find  in  chronic  hip  disease." 

Here  we  have  a  synopsis  of  the  results  —  three  conditions  :  Fii^st, 
restored  to  a  useful  limb  ;  second,  the  wound  remains  open  for  an 
indefinite  period  ;  tliird,  having  a  useless  limb  and  open  wound  — 
in  fact  relapses  into  much  the  same  state  as  we  usually  find  in 
chronic  hip  disease.  Is  it  possible  that  a  wise,  deliberate  considera- 
tion of  these  unfavorable  results  from  excision  of  the  head  of  the 
thigh  bone  should  be  accepted  as  admissible  surgery,  when  it  can 
be  shown,  from  careful  record,  that  not  more  than  five  per  centum 
die  from  the  sequellge  of  the  ailment  in  the  third  stage,  under  ex- 
pectant treatment  :  that  is,  a  judiciously  prescribed  regime  of  con- 


292  Or  tiiop^dia  . 

jBtitutional  treatment.  This  author  then  states,  in  regaid.  to  his 
^'fair  classification  for  practical  purposes:"  "  Taken  in  tliis  way  my 
nineteen  cases  will  show,  in  the  first  place,  seven  deaths,  in  six  of 
which  I  should  refer  the  fatal  issue  to  the  direct  effects  of  the  oper- 
ation, five  of  them  dying  of  pyaemia,  and  one  of  gangrene  of  the 
wound.  The  other  died  of  causes  that  had  been  acting,  I  believe, 
before  the  operation,  which  had,  in  fact,  been  put  off  till  the  patient 
was  in  a  dying  condition.  In  one  of  these  cases  which  died  of 
pygemia,  the  consequence  of  acute  osteomyelitis  of  the  femur,  I 
amputated  the  limb  at  the  hip,  with  the  desire,  if  possible,  of  remov- 
ing the  cause  of  pyaemia,  but  unsuccessfully,  inasmuch  as  deposit  in 
the  lungs  had  already  occurred,  as  was  shown  by  post  mortem 
examination.  In  another  case  I  amputated  with  success,  the  oper- 
ation having  been  followed  by  chi'onic  osteomyelitis  of  the  femur. 
Ea]3id  recovery  ensued,  but  the  patient  had  had  cerebral  symptoms 
before  the  operation,  and  he  died  of  abscesses  of  the  brain  some 
months  after  amputation. 

"  Two  other  cases  have  died  since  the  operation,  but  at  periods  of 
time  very  remote  from  that  of  the  excision,  and  from  causes  quite 
unconnected  with  it.  In  one  of  these  cases  (Isaac  Kichards)  disease 
showed  itself  in  the  opposite  hip  to  the  one  excised,  and  soon  went 
on  to  abscess.  The  boy  lingered  for  a  long  while  in  an  asylum  for 
incurables,  where  he  ultimately  died.  In  another  case  (Margaret 
Horing)  though  she  recovered  from  the  operation,  never  had  any 
use  of  the  limb,  which  remained  in  a  chronic  condition  of  suppura- 
tion. This  leaves  nine  cases,  one  of  which  (Alfred  Davis)  is,  I  think, 
in  an  incurable  condition,  and  will  probably  ultimately  die.  One 
who  has  been  twice  operated  on  (William  Morgan)  I  have  not  seen 
for  a  long  while.  When  last  seen  he  was  improving  in  general 
health  and  in  flesh,  but  the  limb  was  much  shortened  and  distorted, 
and  there  were  still  open  wounds  leading  to  softened  bone.  In  two 
others  (Lydia  Smith  and  George  Punter)  I  think  ultimate  success 
is  likely  to  be  obtained,  though  in  the  former  certainly  with  much 
deformity  of  the  limb.  In  two  other  children  (James  Tapson  and 
Lydia  Bygrave)  the  sores  are  nearly  healed,  and  the  limb  is  very 
useful.  Success  is  nearly  certain,  I  should  hope,  in  those  cases." 
[The  writer  states  that  two  recovered.]  "  Two  others  are  walking 
about  with  useful  limbs,  the  wounds  being  perfectly  sound  (William 
Watts  and  Mary  Ann  Hall).  In  Margaret  Kirby's  case  the  result 
was  equally  good;  but  the  child  died  some  time  after  recovery  from 


Diseases  of  the  Joints.  293 

an  accidental  attack  of  pneumonia,  not  tubercular.  Thus,  out  ol 
nineteen  cases, 

"  6  died  from  direct  effects  of  the  operation  (in  one  case  after 
amputation). 

"  1  died  after  the  operation  from  the  previous  effects  of  the 
disease. 

"  1  died  of  independent  disease  some  time  after  recovery  from 
amputation. 

"2  recovered  from  the  operation,  but  not  from  the  disease,  aiid 
died  a  long  while  afterward. 

"  2  were  little,  if  at  all,  benefited. 

"  1  (twice  excised)  was  doubtful. 

"  3  have  useful  limbs,  but  with  sinuses. 

"  3  recovered  completely." 

This  author  continues  his  remarks  on  excision  of  the  hip,  and 
asserts  that  Dr.  Hodges'  work  on  this  subject  is  the  most  trust- 
worthy which  has  yet  appeared,  and  it  is  stated  that  out  of  111 
cases,  53  terminated  in  death  and  two  in  amputation,  while  56  re- 
covered with  more  or  less  useful  limbs ;  but  it  appears  that  the  evi- 
dence of  the  power  of  walking  was  obtained  in  only  34  of  these.  I 
have  already  pointed  out  elsewhere  the  fallacious  naturcof  what  are 
called  the  statistics  of  most  of  these  surgical  operations,  and  have 
shown  that  there  is  every  reason  to  believe  that  the  success  of*  the 
excision  of  the  knee  joint  has  been  much  exaggerated  by  the  en- 
thusiastic partisans  of  that  operation,  and  that  it  has  really  been, 
on  the  whole,  far  less  successful  than  the  amputations  of  the  thigh 
performed  in  similar  cases,  viz. :  in  chronic  disease  of  the  knee.  But 
I  do  not  on  that  account  dissuade  excision  of  the  knee  when  applied 
to  appropriate  cases;  nor,  if  the  mortality  after  excision  of  the 
hip  could  be  shown  to  be  even  higher  than  fifty  per  cent,  should  I 
admit  that  fact  as  a  valid  argument  against  operating  in  any  given 
instance."  * 

In  this  reasonable  conclusion  of  the  writer,  we  fully  concur. 
There  are  cases  that  present  of  sad  deformity  from  a  dislocation  of 
the  head  of  the  thigh  bone  resting  firmly  in  the  ischiatic  notch,  the 
result  of  unfavorable  position  of  the  limb  during  the  destructive 
processes  of  the  tissues  about  the  hip  joint,  and  the  disease  having 
subsided  leaving  the  patient  in  a  tolerable  condition  of  health. 
Excision  of  the  head  of  the  thigh  bone  tending  to  the  redressing 

*  A  paper  by  T.  Holmes  —  London  Lancet,  October  39,  1864. 


294  Orteop^dia. 

of  the  limb  to  a  vertical  position  with  the  body,  would  most  cer- 
tainly justify  the  operation.  In  such  cases  the  prospect  of  relief 
without  any  great  risk  of  life  to  the  person,  and  a  prospect  of  afford- 
ing an  incalculable  relief  to  the  decrepit  patient,  and  uo  other  relief 
can  be  afforded  when  the  limb  is  thus  situated.  The  thigh  when 
flexed  anteriorly,  and  the  head  of  the  bone  thrown  back  in  the 
fossffi  of  the  ilium,  and  the  inflammation  having  subsided,  and 
before  firm  ligamental  attachment  has  ensued,  can  be  readily  re- 
dressed to  a  vertical  bearing  with  the  body,  and  the  limb  maintain 
its  length  within  an  inch,  by  the  application  of  the  apparatus  repre- 
sented in  Fig.  113. 

Another  very  eminent  authority  is  Kichard  C.  Barwell,  F.R.C.S., 
assistant  surgeon  to  Charing  Cross  Hospital.  In  a  treatise  on 
"Diseases  of  tlie  Joints,"  page  431,  he  says:  ''Since  1848  the 
operation  has  been  increasing  in  credit,  both  in  England  and  in 
Germany  (White  operated  in  1832,  Hewson,  of  Dublin,  in  1828), 
and  we  are  now  able  to  give  a  succinct  account  of  its  effects.  I 
can  thus  gather  altogether  104  cases.  Twelve  times  the  operation 
was  performed  for  injury  (eleven  times  gunshot  injury,  once  for 
fracture  of  the  neck  of  the  thigh  and  descending  ramus  pubis.)  Of 
these  twelve  cases  but  one  recovered.  Of  92  cases  in  which  joint 
diseases  was  the  cause  of  operation,  we  find  that  56  recovered,  32 
are  dead,  4  remain  uncertain.  Therefore,  in  88  cases  56  recover. 
*  *  *  It  must  be,  nevertheless,  acknowledged,  that  several  of 
the  patients,  after  having  lived  and  even  walked  about  for  some 
months,  or  even  more,  ultimately  succumbed  to  internal  disease, 
generally  to  tuberculosis. 

Concerning  the  power,  or  use  of  the  limb  afterward,  it  is  neces- 
sary to  speak  with  the  greatest  caution.  Very  many  of  the  cases, 
after  having  been  reported  as  cured,  with  perfect  use  of  the  limb, 
have  been  lost  sight  of  just  when  the  critical  time  for  testing  the 
use  of  the  member  has  arrived.  Many  of  these  are,  I  believe,  dead; 
others  have  not  so  much  use  of  the  limb  as  the  first  result  of  the 
operation  might  lead  us  to  expect.  "We  may  tabulate  the  only  at- 
tainable numbers  thus;  but  the  quality  of  "useful  limbs"  is  very 
much  too  high.  Of  the  56  recoveries  I  get  no  reliable  informa- 
tion in  14  —  in  6  the  limb  is  useless,  in  36  the  limb  is  reported  as 
useful." 

In  a  foot  note  of  this  reliable  authority  he  remarks :  "  I  am 
greatly  assisted  by  a  valuable  paper  by  Dr.  C.  Fock,  of  Magdeburg, 


Diseases  of  the  Joints.  295 

in  the  Archiv  der  Chirurgie.  The  cases  which  he  has  gathered 
together  are  90 ;  46  English,  7  American,  34  German,  2  French.  1 
Belgian.  *  *  *  These  numbers  are  thus  got  together:  Dr. 
Fock  gives  of  all  his  90  cases,  78  as  being  performed  for  joint 
disease;  of  these  38  recovered,  26  died,  14  are  doubtful.  He  ob- 
tains authentication  of  a  useful  limb  in  22  cases  only.  I  obtained, 
through  the  kind  replies  of  the  profession  to  my  inquiries,  authen- 
tication of  useful  limb  in  6  out  of  the  14  cases  he  was  obliged  to 
leave  uncertain,  and  of  8  out  of  the  14  which  I  have  added  to  this 
table." 

We  have  presented  this  extended  evidence  of  the  unfavorable  re- 
sults of  excision  of  the  head  of  the  thigh  bone  to  sustain  our  posi- 
tion in  refusing  to  sanction  it  as  a  favorable  means  of  relief  in  the 
advanced  stage  of  morbus  coxarius ;  and  more  especially  when  it  is 
known  to  general  practitioners,  that  not  five  per  cent  die  from  even 
the  sequence  of  the  ailment,  under  an  ordinary  careful  regime,  as 
that  afforded  in  a  comfortable  home,  and  judicious  medical  advice. 
The  patients  themselves  are  evidence,  having  recovered  with  short- 
ened legs  and  numerous  cicatrices  —  true  indications  of  the  loss  of 
bone  tissue,  and  the  former  existence  of  extensive  sinuses,  and  drain 
of  serum  attended  with  all  its  depressing  influence  upon  the  system. 

Then,  under  this  ordinary  favorable  condition  of  patients  thus 
afflicted,  is  it  not  possible  in  a  well  regulated  sanitarium  to  not  only 
mitigate  a  vast  amount  of  suffering,  but  shorten  its  duration,  and 
in  ratio  to  the  stamina  of  the  patient,  —  thus  presenting  the  most 
feasible  and  favorable  means  of  saving  the  patient's  life,  by  expect- 
ant treatment  under  such  favorable  circumstances? 

Treatment.  —  Mr.  Thomas  Holmes,  on  the  Surgical  Treatment  of 
the  Diseases  of  Children,  p.  444,  (Lond.  Ed.),  says  :  ''  There  is 
hardly  an  early  case  of  hip  disease  which  is  not  curable  if  the 
patient  can  obtain  careful  nursing,  prolonged  repose,  plenty  of  fresh 
air,  good  diet,  and  an  appropriate  medical  treatment."  One  of  the 
essentials  is  fresh  air,  which  cannot  be  made  available  when  the 
weights  and  pulleys  are  applied  for  treatment ;  nor  can  there  be  a 
desire  for  a  "good  diet"  if  the  quiescent  condition  of  confinement 
to  bed  is  enforced.  To  have  a  desire  for  nutritious  food  an  expen- 
diture of  vital  force  is  imperative.  Muscular  motion  and  fresh  air 
are  the  excitants  to  appetite  for  nutrition  —  the  latter  being  essen- 
tial to  the  accumulation  of  vital  force  and  recuperative  tendency. 
Enforced  eating  of  nutritious  diet  engenders  pathological  conditions 


296  Orthopjedia. 

of  the  digestive  organs  decidedly  inimical  to  the  restorative  powers 
of  the  system,  and  more  especially  when  there  is  no  expenditure  ol 
muscular  energy.  Hence,  we  are  opposed  to  confining  patients  to 
bed  in  any  chronic  ailment,  and  especially  diseases  of  the  joints. 

The  disease  being  located  in  any  of  the  joints,  we  know  but  little 
difference  in  regard  to  treatment.  It  is  an  ailment  impairing  and 
destroying  the  integrity  of  a  joint,  or  joints,  peculiar  in  character, 
and  the  result  of  a  specific  condition  of  the  system  tending  to  that 
end.  If  this  were  not  the  case,  all  bruises  and  injuries  would  pro- 
duce synovitis,  and  in  the  joint  sustaining  the  violence ;  but  it  is 
well  known  that  such  is  not  the  case.  Children  receive  great  in- 
juries from  falls  and  bruises  that  do  not  result  in  hip  diseases  or 
caries  of  the  spine.  Admitting  this  fact  we  must  consider  the 
patient  as  laboring  under  a  peculiar  organic  dyscrasia  that  deter- 
mines the  chronic  character  of  the  ailment  —  and  failure  of  assimi- 
lation, to  a  normal  condition  of  the  person.  Confinement  to  bed 
cannot  improve  this  condition ;  and  upon  this  ground  we  oppose 
its  adoption  in  the  treatment  of  this  disease. 

To  assure  the  reader  that  we  are  sustained  in  our  conclusions  in 
regard  to  this  matter,  we  refer  to  a  treatise  on  hip  joint  disease 
written  by  William  Coulson,  Surgeon  to  the  Magdalen  Hospital, 
Consulting  Surgeon  to  the  City  of  London  Lying-in  Hospital,  Fel- 
low of  the  Royal  Medico-chirurgical  Society  of  London,  Corre- 
sponding Member  of  the  Medico-chirurgical  Society  of  Berlin,  pub- 
lished in  1841,  —  about  the  time  we  commenced  a  careful  investiga- 
tion of  the  pathological  condition  of  patients  laboring  under  this 
class  of  ailments.  This  eminent  practitioner  in  surgery  —  and  so 
considered  by  James  Jon  sen,  M.  D.,  editor  of  the  Medico-chirurgi- 
cal Review  of  that  day,  as  will  be  seen  —  entertained  the  same  views, 
and  long  experience  on  our  part  has  fully  confirmed  our  opinion  in 
their  favor.     He  says  : 

"  In  this  class  of  patients  rest  should  not  be  so  strictly  prescribed 
as  to  endanger  the  health  of  the  patient.  To  obviate,  in  some 
degree,  the  ill  consequences  of  want  of  exercise,  the  patient  should 
be  taken  as  much  as  possible  into  the  open  air,  which  acts  as  a 
stimulus  to  the  vital  powers ;  and  gentle  exercise,  provided  pain  in 
the  joint  does  not  follow,  may  be  allowed.  The  difficulty,  in  these 
cases,  is  to  know  at  what  precise  periods  of  the  disease  does  more 
than  Increased  synovial  secretion  take  place,  and  the  irritation 
which  attends  it,  and  at  what  period  does  organic  change  or  injury 


Diseases  of  the  Joints.  297 

of  the  synovial  membrane  supervene.  In  fact,  I  firmly  believe  that 
the  doctrine  of  rest  is  carried  to  too  great  an  extreme,  and  that  mod- 
ified exercise  is  of  vast  importance  in  this  disease."  Lugol  seems  to 
entertain  the  same  opinion.*  "  I  may  ventnre,"  says  Dr.  L.,  "  to 
solicit  the  notice  of  practitioners  to  the  results  of  my  general  experi- 
ence in  which  I  never  observed  any  accident  or  inconvenience  to 
result  from  this  innovation  (the  employment  of  exercise).  Ot 
seventy-six  scrofulous  patients  at  present  in  my  wards,  there  are 
thirty-two  who,  if  treated  according  to  the  too  general  custom, 
would  be  restricted  to  absolute  confinement  to  bed,  under  my  direc- 
tion, walk  daily  in  the  hospital  promenade  in  the  same  manner  as 
the  different  individuals  afiQicted  with  other  forms  of  the  malady. 
The  study  of  scrofula,  as  regards  its  causes  and  diagnosis,  denotes 
that  this  disease  has,  for  its  general  character,  an  original  weakness, 
which  arrests  the  development  of  organs,  but  which  renders  them, 
subsequently,  subject  to  a  sudden  and  exaggerated  increase.  Eest 
has  even  been  regarded  as  a  debilitating  agent ;  it  is  the  ordinary 
associate  of  all  antiphlogistic  systems  of  treatment.  The  most  vig- 
orous and  robust  constitution  would  inevitably  be  weakened  and 
brought  to  a  state  of  etiolation  by  long-continued  repose.  If  rest 
thus  debilitates  the  vigorous,  still  more  should  an  invalid  of  primary 
weak  constitution  be  enfeebled  by  its  operation,  and  his  malady 
proportionately  increased.  But,  the  matter  is  not  one  of  argument 
alone ;  visit  those  patients  confined  to  bed  for  six  months,  and  on  a 
debilitating  regimen  ;  they  are  pale,  emaciated,  weak  and  depressed. 
I  admit  that  the  motion  of  a  diseased  joint  is  attended  with  some 
inconvenience,  but  the  advantages  derived  from  it  are  very  great  — 
beyond  all  proportion.  In  fine,  for  three  years  that  I  have  followed 
this  method,  I  have  never  been  induced  to  change  it,  or  even  modify 
it  but  for  a  transitory  period  in  some  unusual  cases." 

From  this  inactivity  of  the  system  the  digestive  processes  are 
rendered  torpid,  and  a  failure  to  supply  nutrition  ensues,  which 
results  in  the  tendency  of  impairing  all  the  normal  functions  of  the 
entire  organization.  This  may  be  placing  the  subject  of  dieting  in 
a  strong  light,  but  it  is  none  the  less  true.  If  patients  are  not  thus 
carefully  regulated  for  treatment,  their  ailment  will  fail  to  be  re- 
lieved under  the  most  persistent  and  careful  local  treatment.  It 
must  be  borne  in  mind  that  the  local  ailment  is  a  manifestation  of 
a  dyscrasia,  or  constitutional  degradation  from  a  normal  condition, 

On  Scrofula,  p.  148;  trans,  by  W.  B.  O'Shaughnessy,  M.  D. 


298 


Orthop^dia. 


and  requiring  restoration  before  the  local  ailment  can  be  cured ;  as 
it  is  sustained  by  all  of  the  morbid  secretions  of  deficient  assimila- 
tion. Hence  an  approach  to  a  healthy  condition  of  the  patient 
must  be  attained  to  even  favor  an  arrest  of  the  local  disease.  Pallia- 
tives may  relieve  extreme  suffering,  and  are  of  great  value  to  the 
patient  during  the  preparatory  efforts  to  progress  in  cure,  which  is 
dependent  upon  the  normal  stamina  of  the  individual  when  in  that 
critical  condition.  Hereditary  inflaence  is  here  to  be  considered, 
and  abuse  of  constitutional  powers,  which,  under  a  careful  regime, 
are  subject  to  much  improvement  —  tending  to  the  cure  of  other 
local  ailments. 

As  we  have  before  stated,  the  muscles  and  blood-vessels,  and  also 
that  condition  of  the  nervous  centres,  resulting  from  the  use  of 
tonics,  by  which  they  are  enabled  to  exercise  their  power  more  ener- 
getically, and  give  greater  force  to  the  arrest  of  disturbing  influ- 
ences. Such  influence  is  exhibited  in  the  control  evinced  by  some 
of  the  tonics  over  various  diseases  ;  as  chorea,  epilepsy,  and  neu- 
ralgia. 


SPECIAL   TEEATMENT. 

It  is  in  the  second  stage — havihg  failed  to  arrest  the  disease  in 
the  first  —  that  treatment  yet  gis^es  promise  of  saving  the  patient, 
and  even  from  much  deformity  of  the  limb.  Hygienic  treatment 
has  been,  and  is  yet,  of  much  importance,  including  that  of  alter- 
ative tonics:  hydrarg.  bichloridum,  tr.  cinchonas,  potass,  iodidi, 
Fig.  109.  o^-    morrhuas,    and    the   several    preparations   of 

iron.  'J'he  roller  applied  to  the  hips  over  cotton 
batting  is  as  important  as  in  the  first  stage 
of  the  disease.  The  manner  of  applying  the 
roller  is  seen  in  Fig.  109.  Fresh  air,  moderated 
exercises,  nutritious  diet  and  cheerful  entertain- 
ment tends  the  most  largely  to  the  cure.  Noth- 
ing is  more  prejudicial  than  monotonous  confine- 
ment ;  as  that  of  confining  the  patient  to  bed.  In 
more  than  a  majority  of  cases  thus  treated  (as  we 
have  witnessed),  the  progress  of  the  disease  has  not 
been  arrested,  but,  in  our  opinion,  rendered  ob- 
scure because  of  the  relief  from  pain  obtained  by 
the  sedative  effect  of  the  continued  extension  made 
by  means  of  weight  and  pulleys,  to  the  impair- 


Diseases  of  the  Joints.  299 

ment  of  nutrition  and  normal  excitability  of  the  limb  —  this 
being  in  accordance  with  admitted  physiological  laws;  that  is, 
that  free  contraction  and  extension  of  the  muscles  is  essential 
to  the  maintenance  of  the  normal  increase  from  assimilation 
in  the  animal  system.  The  most  nutritious  diet,  and  a  desire 
for  it,  affords  no  strength  if  there  is  not  an  expenditure  of  muscular 
energy.  Witness  the  idle  gourmand,  and  compare  him  with  the 
laborer.  The  system  becomes  torpid  from  confinement,  both  physi- 
cally and  mentally,  tending  to  a  concentration  of  excitement  in  the 
diseased  hip,  or  other  parts  similarly  afiected  and  sustained  at  the 
expense  of  the  general  system.  Hence,  the  demand  for  general  and 
local  treatment;  general,  in  order  to  obtain  and  maintain  an  equi- 
librium of  excitement  in  all  parts  of  the  system,  and  local  treatment 
to  remove  the  cause  of  excitement  in  the  part  affected.  The  primary 
local  invasion  being  probably  a  constriction  of  the  peripheral  to 
the  engorgement  of  the  larger  blood-vessels  with  an  excess  of  serum, 
and,  from  distension,  pain  arises,  indicating  the  relief  that  should 
be  afforded  to  the  arrest  of  the  tendency  to  disorganization  of  the 
locally  distended  tissues.  Now,  whatever  will  tend  to  this  relief  is 
applicable  in  the  first  stage  as  in  the  second,  and  in  the  first  gives 
greater  promise  of  permanent  relief.  In  the  second  stage  the  relief 
may  not  be  as  permanent  because  of  the  impairment  of  the  impli- 
cated tissues  —  they  having  become  weakened  from  the  duration  of 
distension.  This  distension  consisting  largely  of  serum,  an  effort 
must  be  made  to  lessen  the  excess  by  derivatives,  which  have  a  cura- 
tive tendency  by  relieving  the  distended  vessels  ;  leeching,  cupping 
and,  indirectly,  cathartics  tend  decidedly  to  this  relief,  but  greatly 
reduce  the  patient's  strength.  Vesication  is  not  so  objectionable 
when  freely  poulticed  and  treated  as  a  derivative,  and  not  as  an 
irritant  bv  dressings  of  stimulant  ointments.  Vesication  is  an 
invaluable  therapeutic  agent  for  the  purpose  intended,  as  irritants 
in  the  region  of  the  lesion  are  inimical  because  of  their  increasing 
the  morbidly  localizing  tendency  in  the  part  affected.  The  curative 
tendency  is  to  lessen  the  engorgement.  This  relieves  pain  without 
impairing  normal  sensibility,  and  the  vital  forces ;  and  to  maintain 
the  relief  we  apply  compression,  and  all  therapeutic  agents  having  a 
tendency  to  promote  absorption  or  dispersion  of  accumulated  serum 
in  the  congested  vessels.  Iodine  and  belladonna  are  reliable,  either 
alone  or  in  combination,  also  elastic  compression,  such  as  cotton 
batting  applied  with  the  roller  after  having  reduced  temperature. 


300  Orthop^dia. 

which  should  be  carefully  determined  by  the  thermometer  of  Dr.  Se 
guin,  constructed  for  the  purpose  of  determining  comparative  tem 
perature  in  different  parts  of  the  person,  and  the  excess  of  heat, 
v/hen  localized.     Cold  water  frequently  applied  by  means  of  a  folded 
towel  or  something  sufficiently  large  to  retain  moisture. 

^-                                  ■  _  . 

Amnion,  clilor |  i 

Plumbi    acet 3  ii 

Tr.   opii I  ii 

Acid   acetic. 

Aq.  font aa    %  viii. 

Mr. 

Ft.  loti 

This  lotion  freely  applied  affords  much  relief  from  active  inflam- 
mation and  pain,  obviating  the  necessity  in  some  cases  for  vesica- 
tion and  poulticing.  It  is,  however,  the  safest  practice  to  vesicate 
freely  while  pain  and  swelling  continue  even  to  the  extent  of  eight 
or  ten  repetitions — healing  having  been  permitted  between  each 
renewal  of  vesication. 

It  is  in  the  second  stage  that  the  limb  becomes  powerless  and 
presents  an  apparent  diminution  in  circumference  compared  with 
the  fellow  limb,  while  the  pain  at  the  knee  becomes  more  severe 
and  the  tendency  to  shorten  increases.  An  increase  of  tempera- 
ture, exceeding  that  of  the  body  several  degrees,  will  now  be  observ- 
able, and  as  the  disease  advances  the  pulse  becomes  accelerated,  the 
face  alternately  pale  and  flushed,  the  skin  moist  and  clammy,  thev 
tongue  white,  and  the  person  emaciated.  The  patient  starts  and 
screams  out  during  sleep  from  distress  occasioned  by  involuntary 
contraction  of  the  irritated  muscles.  Through  all  the  increase  of 
suffering,  in  many  cases,  there  will  not  be  any  appearance  of  abscess 
forming,  while  the  leg  is  shortened  two  or  three  inches.  In  some 
cases  a  deceptive  interim  ensues  —  an  entire  remission  of  all  the 
symptoms,  at  least  the  painful  ones,  and  yet  the  disease  advances 
to  the  third  stage.  When  indolent  abscesses  form  we  do  not  open 
them  but  apply  the  roller  firmly,  or  have  a  lacing  applied,  as  it  is 
more  permanent  than  the  roller,  and  by  this  means  often  dispel 
even  abscesses  of  large  size. 

The  second  having  advanced  to  the  third  stage,  a  most  formidable 
set  of  symptoms  supervene.  The  elongated  limb  shortens  so,  that 
the  extremity  of  the  metatarsals  and  toes,  only,  touch  the  ground, 


Diseases  of  the  Joints. 


301 


Fig.  110. 


and  when  in  the  erect  position  the  patient  places  the  foot  of  the 
shortened  limb  on  the  dorsum  of  the  foot  of  the  sound  side,  but  if 
attempting  to  walk  everts  the  foot  of  the  impaired  limb.  It  is  the 
exception  to  see  them  turn  the  toes  inward.  The  stick  will  now  no 
longer  serve  the  patient  in  walking,  and  the  crutch  must  be  resorted 
to  as  a  means  of  avoiding  pain  when  compelled  to  move  about. 
When  in  the  house  the  safest  means  of  support  for  the  patient  is, 
to  push  a  chair  before  him,  especially  if  he  be  a 
child,  as  the  crutch  is  liable  to  slip  and  let  the 
patient  fall,  to  the  great  injury,  and  often  to  the 
dislocation  of  the  thigh  bone  upon  the  dorsum  of 
the  ilium.     See  Fig.  110. 

This  unfortunate  occurrence  demands  prompt 
tittention.  An  ansesthetic  should  be  resorted  to, 
and  the  dislocation  reduced.  The  muscles  being 
impaired  in  tone  do  not  offer  the  resistance  of 
muscles  when  in  a  normal  condition,  but  there  is  a 
■decided  tendency  of  the  head  of  the  bone  toward 
escaping  again,  spontaneously,  from  the  acetabulum. 
To  arrest  this  tendency,  before  or  after,  we  apply 
an  extension  suj)port,  used  in  other  conditions  of 
the  diseased  limb  —  that  is,  when  inflammation  is  subdued  —  in 
hip  disease  aud  in  cases  of  dental  paralysis. 

Fig.  Ill  represents  an  extension  apparatus.  Two  fixed  points  of 
extension  are  observable,  a  cushioned  strap  crossing  the  perineum 
and  attached  to  a  steel  belt  encircling  the  hips. 
Two  vertical  bars  of  steel  having  encircling  steel 
belts  to  inclose  the  limb,  being  secured  by 
leather  straps  ;  the  foot  resting  on  a  plate  of  steel 
having  an  encircling  cup  for  the  heel,  and  the 
foot  held  firmly  by  a  leather  band  crossing  the 
instep.  The  inner  vertical  bar  extends  upward 
to  within  two  inches  of  the  perineum,  the  outer 
bar  having  a  joint  about  two  inches  from  its  at- 
tachment to  the  hip-band  corresponding  to  the 
hip  joint,  or  means  of  obviating  an  anchylosed  con- 
dition of  the  joint,  movement  being  made  available, 
to  the  head  of  the  thigh  bone  maintained  in  situ 
by  the  appliance.  The  method  of  applying  the 
fupport  may  be  thus  described  :   The  hips  being  firmly   encircled 


Fig.  HI. 


302 


Orthopjedia. 


Fig.  112. 


with  a  roller,  as  seen  in  Fig.  109,  the  leg  is  then  placed  in  the 
frame,  and  the  foot  banded  to  the  foot-plate.  The  band  encircling 
the  hips  is  then  secured  and  the  perineal  strap  tightened  to  the 
extent  of  the  patient's  endurance.  By  this  means  the  limb  is  sup- 
ported, which  support  should  be  continued  until  the  limb  is  firmly 
attached.  Erom  the  use  of  this  appliance  a  favorable  result  is  often 
obtained  -without  anchylosis  —  restoration  from  the  disease  having 
ensued. 

Fig.  112  represents  the  apparatus  unapplied,  with  or  without  a 
joint  at  the  knee  (A).     B,  the  form  of  the  joint  having  a  slide  to  fix 

the  joint,  if  desired.  C,  the  instep  strap 
to  secure  the  foot  for  extension  at  the  hip. 
This  we  devised  for  this  purpose,  and 
applied  it  to  many  cases  during  the  past 
twenty  years,  in  all  cases  after  inflamma- 
tion had  been  subdued,  and  mobility  in 
the  limb  sustained,  thus  enabling  the- 
patient  to  walk  without  the  support  of  a 
crutch.  The  use  of  the  crutch  is  objec- 
tionable because  of  its  tendency  to 
shorten  the  limb  by  the  adaptation  of 
the  sj)ine  to  the  obliquity  of  the  pelvis  — 
the  diseased  hip  being  elevated  —  hence 
the  necessity  for  enabling  the  patient  ta 
place  the  entire  foot  upon  the  ground,  to- 
stand,  and  then  to  push  a  chair  before- 
him  and  walk. 

In  regard  to  shortening  of  the  limb,  much  difference  of  opinion- 
has  been  expressed  by  authorities  upon  the  subject.  It  is  in  the- 
third  stage  of  the  ailment  that  we  have  the  bones  actually  diseased. 
In  the  first  and  second  stages,  the  disease  is  mainly  limited  to  the 
surrounding  tissues,  tending  to  indolent  abscess,  that  by  improve- 
ment of  the  physical  condition  of  the  patient,  and  the  application 
of  elastic  compression,  even  when  as  large  as  half  a  goose  egg,  often 
disappear  and  the  patient  relieved — without  a  limp.  In  the  third 
stage,  however,  the  shortening  of  the  limb  becomes  most  decided,, 
and  there  is  apparent  dislocation  of  the  head  of  the  thigh  bone  upon 
the  dorsum  ilii  and,  as  we  have  seen  cases,  into  the  ischiatic  notch  ;, 
this  last  probably  arising  from  accidental  cause.  When  dislocated, 
upward  and  backward,  Mr.  Nelaton   gives  a  mode  of  determining 


Diseases  of  the  Joints. 


303 


the  condition:  "When  in  the  normal  position,  if  a  string  is 
stretched  from  the  anterior  or  superior  spinous  process  of  the  ilium 
to  the  lower  edge  of  the  tuberosity  of  the  ischium  it  will  touch  the 
upper  margin  of  the  trochanter  major  of  the  thigh  bone.  If  dislo- 
cated upon  the  dorsum  of  the  ilium  the  line  will  be  entirely  below 
the  trochanter."  This  learned  gentleman  states  that  this  will  deter- 
mine the  question  as  to  the  dislocation  of  the  head  of  the  thigh 
bone.  In  advanced  hip-disease  we  have  distinctly  felt  the  head  of 
the  bone  thrown  back  in  the  fossa  of  the  ilium,  two  or  more  inches 
from  the  acetabulum,  and  the  psoas  magnus  and  the  iliacus  inter- 
mus,  tensely  contracted — flexing  the  thigh  upon  the  pelvis,  and 
shortening  the  leg  from  four  to  five  inches.  In  the  early  condition 
of  this  shortening  much  improvement  can  be  made  in  the  straight- 
ening of  the  limb  by  lateral  elastic  force  obtained  from  the  bed- 
frame  represented  in  Fig.  59  ;  the  patient  being  exercised  upon  it 
for  about  fifteen  minutes,  twice  a  day.  Then,  to  maintain  the  im- 
proved condition  of  the  contracted  muscles,  and  admit  of  limited 
motion  in  the  joint,  we  apply  the  bracing  support  represented. 

Fig.  113.  A,  a  steel  frame  encircling  the  body  and  having  lacings 
in  front,  and  straps  to  pass  over  the  shoulders,  and  button  on  the 
back.  B,  steel  springs  having  metal 
discs  padded  and  arranged  so  as  to 
co-aptate  to  the  posterior  part  of  the 
head  of  the  thigh  bone,  and  main- 
tained in  position  by  means  of  a 
leather  strap  attached  to  the  center  of 
the  lower  encircling  band  of  the  body 
brace,  and  from  thence  to  the  pendent 
bars,  of  which  one  or  both  may  be  used. 

The  distal  end  of  the  spring  is  con- 
fined to  the  leg  with  leather  straps, 
giving  force  by  means  of  the  attached 
springs,  the  bone  being  carried  for- 
ward and  the  femur  brought  in  a  ver- 
tical line  with  the  body.  By  this 
means  the  shortening  will  be  limited  to  an  inch  or  an  inch  and  a 
half  at  most.  'Yho,  origin  of  the  glutei  muscles  sustain  the  head  of 
the  bone  partly  on  the  upper  edge  of  the  acetabulum,  a  firm  resist- 
ance being  maintained  when  in  this  position,  and  tolerable  move- 
ment admitted  by  the  sustaining  attachments,  which  health  and 


Fig.  113. 


304 


ORTHOPjEDIA. 


Fig.  Hi. 


time  ensures.  To  relieve  the  deficiency  in  leugtli  of  limb,  a 
wedge-shaped  piece  of  cork  should  be  fit- 
ted within  the  gaiter  (see  Fig.  114).  and 
Avhich  relieve  the  patient  from  any  apparent 
limp. 

The  dotted  line  above  the  sole  of  the  gaifcer 
shows  the  shape  and  j)osition  of  the  cork 
wedge. 

The  redressing  treatment  must  be  com- 
menced as  early  as  the  diseased  condition  of 
the  limb  will  admit,  as  the  more  decided  re- 
lief will  be  obtained ;  although  cases  of  a 
year  or  two's  standing  have  been  much  im- 
proved by  this  treatment. 

The  limit  of  our  work  will  not  admit  of 
a  presentation  of  the  various  opinions  ex- 
pressed, or  theories  advanced  in  regard  to  the  different  pathologi- 
cal conditions  attending  hip  disease ;  nor  is  it  in  accordance  with 
the  design  of  our  clinical  remarks,  which  is  intended  only  to  present 
the  result  of  our  own  experience  in  the  treatment  of  diseases  as 
stated,  and  also  of  the  means  of  relief,  when  curable,  and  in  cases 
of  confirmed  displacement  and  shortening  of  the  limb  as  in  the  case 
of  the  loss  of  the  toes  or  permanent  shortening  of  the  limb. 

Fig.  115  A,  represents  an  appliance  to    be  used  when  the  toes 

have  been  amputated.     A  steel  plate  to  the  sole  of  the  foot  extended 

F/y.  115.  ^°  ^^®  length  of  its 

^  fellow,  and   having 

cork  shaped  t  o 
the  form  of  the 
missing  toes  at- 
tached. A  metal 
cup  to  secure  the 
heel,  covered,  and 
laced  upon  the  in- 
step ;  upright  bars 
having  metal  en- 
circling bands  about 
the  leg,  and  at  the 
ankle  a  limited  joint 
to  resist  the  tendencv  of  the  gastrocnemius  muscles  from  shorten- 


Diseases  of  the  Joints.  305 

ing,  having  been  relieved  by  the  severing  of  the  flexor  tendons. 
This  simple  appliance  we  devised  some  twenty  years  since,  and 
have  found  it  to  answer  the  purpose  intended,  namely,  that  of  a 
resistance  to  the  shortening  of  gastrocnemius  muscle,  and  retaining 
the  foot  at  a  right  angle  with  the  leg ;  thus  enabliiig  the  patient 
to  walk,  after  some  practice,  without  a  limp. 

B,  is  an  artificial  foot  attached  to  an  ordinary  gaiter  having  a 
steel  plate  fitted  to  the  sole,  and  upright  pieces  to  support  the  ankle. 
This  was  devised  mainly  for  women,  and  some  time  previous  to  the 
appliance  C. 

G,  is  for  a  similar  purpose,  being  m'ore  convenient  for  men,  and, 
we  believe  preferable  to  the  ordinary  cork  sole.  This  having  steel 
wire  studs  supporting  two  steel  plates,  one  attached  to  the  shoe  and 
the  other  covered  with  leather,  having  a  toe-piece  and  heel  of  sole 
leather. 

PROGNOSIS    OF   UNFAVORABLE    CASES. 

Having  considered  the  cases  that  are  subject  to  remedy,  we  will 
now  notice  cases  that  tend  to  a  fatal  termination,  yet,  with  careful 
treatment,  many  recover  to  a  tolerable  condition  of  health,  and 
strength  of  the  diseased  limb. 

It  is  in  this  advanced  stage  of  the  ailment  that  we  observe  the 
constitutional  tendencies  to  destructive  disease,  being  at  first  con- 
lined  apparently  to  the  hip,  but  now  extended  to  the  involving  of 
the  entire  system.  Inflammation  has  extended  its  destructive  influ- 
ence to  all  the  surrounding  tissues  of  the  hip,  involving  the  bones 
of  the  pelvis.  The  nates  have  become  tumefied,  the  surrounding 
cellular  tissue  inflamed  and  the  skin  reticulated  with  distended 
veins;  presenting  reddened  spots  on  the  nates  or  outer  side  of  the 
thigh,  indicating  the  opening  of  sinuses  of  great  depth  and  exces- 
sive drainage. 

Before  opening,  there  is  much  pain  and  hectic  symptoms  ;  the 
glands  in  the  groin  becoming  enlarged  and  painful.  In  some  cases 
the  ulceration  extends  through  the  acetabulum,  forms  a  sac  that 
unites  with  the  intestine  in  the  pelvis  ;  and  by  fistulous  openings 
ihe  matter  passes  into  the  rectum.  The  flatus  passing  through  the 
sinus  indicates  the  extent  and  parts  affected.  We  have  a  case  now 
under  treatment  in  which  foecal  matter  passes  outward  into  the  sac 
of  an  abscess  on  the  front  of  the  thigh  and  escaped  through  an 
opening  three  inches  below  the  groin.  The  matter  from  the  abscess 
is  now  passed  per  anus,  and  the  sinus  on  the  thigh  nearly  closed. 


306  Orthopjedia. 

The  character  of  the  secretion  thrown  off  varies  much  in  quality; 
m  some  it  is  healthy  pus ;  in  others,  fetid  sanies  containing  small 
grains  of  spiculse  of  bone.  The  quantity  and  duration  of  the  dis- 
charge also  varies  greatly ;  continuing  in  some  cases  for  consider- 
able duration  of  time,  and  in  others  ceasing,  and  returning  again, 
and  at  times  with  hemorrhage,  to  the  degree  of  endangering  the 
life  of  the  patient.  In  those  cases  where  the  discharge  is  well- 
formed  pus,  a  favorable  prognosis  can  be  made  ;  but  if  the  discharge 
assumes  the  thin,  dark,  fetid  character,  hectic  fever  ensues,  and  the 
strength  of  the  patient  fails,  but  little  hope  for  recovery  remains. 

Unfavorable  symptoms  ensue  after  spontaneous  discharge,  if  of 
large  quantity  of  pus  and  serum,  and  the  patient  fails  in  strength ; 
but  as  a  general  result,  less  constitutional  derangement  follows  than 
in  the  early  puncturing  of  these  torpid  abscesses.  Time,  in  many 
instances,  tends  to  the  restoration  of  the  general  health  of  the 
patient,  if  so  situated  as  to  have  the  benefit  of  a  proper  regime ; 
when,  under  these  circumstances,  as  before  stated,  large  abscesses, 
in  many  cases  disappear,  and  the  patient  recovers  from  all  indica- 
tions of  the  disease.  This  we  consider  to  be  sufficient  to  justify  a 
reasonable  delay  in  opening  them.  In  cases  where  there  is  much 
suffering  from  distension,  and  the  abscess  tends  to  a  point  that 
would  soon  open,  a  small  opening  affords  relief;  and  a  considerable 
thickness  of  wet  cloths  secured  by  the  roller,  will,  in  many  instances, 
relieve  the  patient  without  shock  to  the  nervous  system.  We  con- 
sider poultices  to  be  injurious  from  their  tendency  to  encourage 
excessive  draining  when  the  abscess  is  open, —  and  he/ore!  A  large 
soft  cloth  folded  and  kept  wet  is  much  more  cleanly  and  quite  as 
efficient  in  reducing  the  heat  and  pain  in  the  tumefied  part.  A 
lotion  of  poppy-head,  hop  tea,  stramonium  leaves,  or,  that  of 
muriate  of  ammonia,  acetate  of  lead  and  opium,  before  mentioned, 
usually  affords  much  relief. 

Most  unfavorable  symptoms  of  general  prostration  follow,  in 
some  cases,  a  spontaneous  opening  of  these  large  abscesses,  even 
under  the  most  careful  treatment,  such  as  excessive  perspiration 
and  colliquative  diarrhoea.  And,  what  is  remarkable,  patients  will 
keep  their  beds  for  months,  wholly  unable  to  help  themselves, 
exceedingly  irritable  and  sensitive  when  handled  for  change  of  posi- 
tion to  their  protection,  comfort  and  preservation  from  bed-sores; 
indicating  carious  bones  and  indurated  tissues  surrounding  them. 
ind  yet,  as  unpromising  as  these  cases  may  appear,  the  patients,  ic 


Diseases  of  the  Joints.  307 

many  instances,  recover  ;  and  more  often  than  in  cases  of  excision 
of  the  head  of  the  thigh  bone,  and,  in  cases  where  nutrition  can  be 
maintained,  much  more  successfully.  Therefore,  we  do  not  con- 
sider excision  of  the  head  of  the  thigh  bone  a  justifiable  treatment 
even  in  extreme  cases. 

Out  of  nineteen  cases  of  excision,  only  three  recovered  completely. 
The  patients  unfavorably  conditioned  as  we  suppose  them  to  have 
been  far  advanced  in  caries  and  necrosis  of  the  bones.  Of  such, 
and  incipient  cases,  we  have  restored  seventy-five  per  cent  to  an 
ability  to  labor — the  disease  having  been  arrested,  with  more  or 
less  shortening.  1326  cases  of  morbus  coxarius,  1679  cases  of 
caries  of  the  spine,  and  798  cases  of  synovitis  of  the  knee,  ankle, 
shoulder  and  elbow,  have  received  treatment  within  the  past  eleven 
years  in  the  Hospital  for  the  Eelief  of  the  Euptured  and  Crippled. 
Of  this  number,  the  most  unfavorable  cases  relieved  of  morbus 
coxarius  were  only  about  two  and  a  half  inches  shortened  by  the 
disease,  and  the  most  of  them  not  over  an  inch  ;  the  thigh  bone 
having  been  brought  to  a  vertical  bearing  with  the  body.  This 
we  accomplish  after  the  active  condition  of  the  disease  has  been 
subdued;  it  being  always  advisable  to  desist  from  posterior  exten- 
sion when  pain  is  induced,  and  to  delay  the  effort  from  time  to 
time,  until  the  patient  can  endure  the  treatment  without  suffering, 
or  risk  of  exciting  inflammation  tending  to  a  return  of  the  former 
morbid  condition. 

We  have  been  considering  the  several  conditions  of  hip  disease  to 
the  most  perplexing  advancement  where  complicated  pathological 
invasions  supervene,  to  the  retarding  of  the  recuperative  tendency. 
In  this  advanced  stage  we  have  a  pyemic  dyscrasia  of  the  vital  func- 
tions and  advancing  to  an  incurable  condition  of  the  patient.  And 
this  dyscrasia  arising  from  the  contents  of  abscess,  the  morbid  con- 
dition of  which  results  from  impaired  nutrition,  inducing  a  cachec- 
tic condition  of  the  system.  To  give  the  least  promise  of  success 
when  in  this  condition,  a  proper  regime  is  of  primary  importance. 
Pure  air,  the  temperature  not  such  as  to  chill  the  body,  pleasant 
mental  excitement  tending  to  muscular  exertion,  the  skin  carefully 
cleansed  and  gently  excited  by  the  warm  hand,  or  flannel,  avoiding 
alcohol  or  any  lotion  that  evaporates  readily,  as  they  diminish  the 
enfeebled  vital  forces  by  reducing  temperature,  and  are  only 
applicable  to  the  reduction  of  local  excitement  and  increased 
temperature   in  the  part.      This   tends   to    a   demand  for    nutri- 


308  Orthop^dia. 

meut,  that  must  be  supplied,  of  easy  digestion  and  in  moderate 
quantity,  and  at  frequent,  stated  intervals.  The  system  respond- 
ing to  this  treatment  will  require  but  a  very  limited  quantity  of 
medicine  of  careful  selection.  Alterative  excitants  are  admissible, 
as  that  of  hydrarg.  bichlor.,  in  tr.  cinchon.  com.,  ferri  iod.,  potass, 
iod.,  and,  in  cases  of  excessive  discharge  from  abscesses,  cod- 
liver  oil,  in  quantity  limited  to  the  power  of  digestion.  If  not 
assimilated,  because  of  excessive  quantity  or  enfeebled  digestive 
powers,  as  before  stated,  it  is  inimical  to  the  digestive  functions, 
and  decidedly  injurious  to  the  patient.  Milk,  yet  warm  from  the 
cow,  beef  tea  made  from  fresh  beef  of  the  best  quality  —  avoiding 
the  fat  —  and  palatably  salted,  properly  fermented  bread,  having 
been  baked  forty-eight  hours,  may  be  considered  as  proper  diet, 
mucilage  made  of  this  bread  is  a  valuable  nutrient  in  cases  where 
the  patient  cannot  relish  the  bread,  and  is  prepared  as  follows: 
four  ounces  of  bread,  eight  ounces  of  boiling  water  poured  upon  it 
and  set  aside  to  cool.  When  cool,  strain,  and  add  one  ounce  of 
best  cognac  brandy  and  two  ounces  of  white  sugar.  The  condition 
of  the  patient  must  determine  the  quantity  of  this  nutrient  to  be 
taken  in  twenty-four  honrs.  Milk,  and  milk  punch  is  a  favorite 
nutrient  Avith  many  practitioners.  Experience  has  rendered  it 
objectionable  in  some  cases,  for  it  is  liable  to  coagulate  and  form  a 
mass  of  curd  in  the  stomach,  which  greatly  distresses  the  patient, 
tending  to  serious  consequences  if  not  ejected  by  an  emetic,  as  we 
have  witnessed  quantities  of  curd  thrown  off,  to  the  great  relief  of 
the  patient.  In  ordinary  cases  the  amount  of  mucilage  must  be 
given  carefully  at  stated  periods,  and  containing  more  brandy  in 
cases  of  diarrhoea,  excessive  discharge  from  abscess,  or  hemorrhage 
caused  from  spiculae  presenting  in  sinuses.  In  cases  of  colliquative 
diarrhoea,  argenti  nitras  in  one-fourth  of  a  grain  doses,  every  four 
hours,  has  been  a  valuable  remedy  in  our  practice,  not  omitting  a 
liberal  quantity  of  opiates.  The  subnitrate  of  bismuth  and  gum 
acacia  affords  most  decided  relief  in  mild  cases. 

Patients  that  have  been  so  much  relieved  by  this  treatment  as  to 
give  promise  of  recovery,  in  many  cases  suffer  from  attacks  of  neu- 
ralgia in  and  about  the  diseased  parts.  For  their  relief  we  have 
found  the  solution  of  potass,  arsenitis  the  most  reliable  remedy  ; 
and  also  in  the  several  stages  of  the  ailment,  increasing  the  quantity 
to  nauseating  the  patient,  if  required,  for  relief.  In  all  cases  where 
tne  stomach  will  bear  a  dose  of  the  decoction,  that  of  cortex  cinch.. 


Diseases  of  the  Joints.  309 

rad.  gentian,  rad.  serpentaria  virg.  and  sem.  cardamom,  may  be 
administered,  and  will  relieve  the  neuralgic  pains,  increase  the  appe- 
tite, and  give  strength  to  the  patient.  One  ounce  of  this  should  be 
given  for  an  hour  after  meals. 

The  treatment  of  the  discharging  abscesses  and  sinuses  demands 
careful  consideration  at  all  stages,  but  more  especially  when 
sphacelus  or  slough  ensues,  leaving  extensive  ulcers  to  treat. 
To  arrest  sloughing,  carbo  ligni,  cinchona,  and  gum  myrrhas,  added 
to  poultices  of  linseed  meal,  is  a  most  reliable  dressing  when  changed 
every  three  or  four  hours.  The  slough  being  detached,  frequent 
pencilling  of  the  ulcer  with  a  solution  of  argenti  nitrat.,  ten  grains 
to  the  ounce,  of  water,  greatly  strengthens  the  rising  granulations. 
For  the  dressing,  carbolic  acid,  and  oil ;  fresh  mutton  tallow,  or 
Turner's  cerate.  If  painful,  a  lotion  consisting  of  the  following 
may  be  applied  as  a  reliable  means  of  relief,  cloths  to  be  kept  satu- 
rated  with  it : 

Zinci  sulph 

Plumbi  acet.  aa  grs vi 

Vin.  opii ^  i 

Aq.  font I  vi 

Ft.  lotio 

This,  however,  gives  only  temporary  relief,  and  the  cause  must  be 
sought  and  a  more  permanent  relief  given.  A  very  common  excit- 
ant is  constipation,  and  torpidity  of  the  liver,  when  the  tongue  will 
be  coated  in  the  centre  and  the  edges  papilated,  and  more  than 
ordinarily  red.  A  decided  purgative  is  then  indicated  that  will  act 
upon  the  entire  alimentary  canal,  producing  watery  evacuations. 
The  patient  will  be  greatly  relieved  by  taking  the  following: 

Hydrarg.  chlor.  mit 

Pulv.  jalapse  aa  grs viii 

Ft.  pulv. 

and  in  eight  or  ten  hours  a  portion  of 

rochelle  salts. 

The  local  treatment  of  these  slouarhs  demands  most  careful  con- 


310  Orthop^dia. 

sideratiou.  The  patient's  strength  must  be  maintained  by  every 
effectual  means.  A  purgative,  as  given  above,  tends  largely  to 
increase  the  appetite,  enabling  him  to  digest  a  greater  quantity  of 
nutritious  diet,  which,  if  persevered  in,  without  the  purgative, 
would  only  over-burden  the  stomach  and  impair  the  appetite, 
inducing  a  disrelish  and  actual  nausea  at  the  sight  of  food. 

In  cases  where  we  have  extensive  sloughing  of  large  sacs,  to  all 
appearances  of  the  cuticle  alone ;  exposing  the  muscular  sheathing, 
and  where  the  edges  are  abrupt  and  seemingly  not  adherent,  with 
sinuses  extending  in  different  directions  to  a  very  considerable 
extent,  these  extensive  secreting  surfaces  tend  greatly  to  the  exhaus- 
tion of  the  patient,  and  must  be  remedied  by  whatever  means  pos- 
sible. Adhesive  strips  approximating  large  openings,  and  elastic 
compression,  has  been  tried  with  the  most  favorable  results ;  ravel- 
ings  from  worn  linen  or  cotton  is  the  material  that  gives  the  most 
comfort  to  the  patient,  as  it  is  soft,  light,  and  not  as  compact  as 
oakum  lint  or  raw  cotton,  for  dressing.  A  firm  bandage,  laced,  is 
preferable  to  the  roller,  and  should  be  applied  as  tightly  as  the 
patient  can  bear.  In  removing  the  dressing,  great  care  must  be 
taken  not  to  elevate  the  edges  of  integument  surrounding  the  ulcer. 
Cleanse  it  with  warm  water  and  a  large  camel's  hair  brush,  in  pref- 
erence to  the  sponge,  and  if  the  discharge  is  fetid,  apply  a  soft 
piece  of  linen  wet  in  Labarraque's  solution  properly  diluted,  carbolic 
acid  and  oil,  or  a  solution  of  ferri  sulph.,  two  drachms  to  the  pint 
of  water.  By  perseverance  iu  the  treatment  of  these  advanced  cases 
when  under  favorable  hygienic  influence,  it  is  only  remarkable  that 
so  few  die  from  the  ailment,  not  one-tenth  of  the  number  that  die 
after  the  exsection  of  the  head  of  the  thigh  bone.  Of  cases  in  their 
incipiency  to  these  advanced  cases,  we  find,  in  our  records,  as  before 
stated,  seventy-five  per  cent  have  been  restored  to  self-sustaining 
ability.  Of  these  cases  two-thirds  were  in  the  second  and  third 
stages  of  the  disease,  having  been  subjected  to  the  weight  and  pul- 
ley treatment ;  and  yet  the  limbs  flexed  more  or  less  upon  the  pel- 
vis. One  case,  inviting  special  attention,  was  a  girl  of  eleven  years 
of  age,  having  both  hips  diseased  and  the  limbs  so  flexed  that  it  was 
impossible  for  her  to  stand  alone.  This  child  had  had  the  heads  of 
the  extensor  femoris  muscles  divided,  and  the  weights  and  pulley 
applied  steadily  for  nine  months,  yet  was  left  in  a  most  decrepit 
condition,  and  the  disease  not  arrested.  In  eighteen  months  this 
child  was  enabled  to  walk,  like  that  of  a  case  of  congenital  disloca- 


-Diseases  of  the  Joints.  311 

tion  of  the  hips  by  the  treatment  herein  described ;  that  is  exten- 
sion produced  by  posterior  force  after  the  inflammation  was  reduced. 

Mr.  Holmes  Coote,  F.  R.  0.  S.,  surgeon  to  St.  Bartholomew's 
Hospital,  London,*  says:  "I  do  no  approve  of  any  attempt  to 
straighten  the  limb  until  all  morbid  action  ceases  and  the  joint  is 
free  from  pain  ;  and  then  extension  should  not  be  so  rapid  and 
forcible  by  which  a  great  amount  of  injury  can  be  effected,  but  it 
should  be  slow  and  gradual  and  effected  by  means  of  proper  ajopa- 
ratus."  Our  experience  fitlly  agrees  with  this  learned  gentleman's 
views  of  extension  in  the  treatment  of  hip  disease ;  that  it  should 
not  be  applied  before  all  inflammation  and  tenderness  is  subdued, 
and  then  with  much  close  observation  to  guard  against  the  tendency 
to  a  renewal  of  the  inflammation. 

There  are  several  ailments  that  assimilate  hip-disease  and  are 
noticed  by  authors  as  that  of  psoas  abscess,  diseased  condition  of 
the  glands  in  the  groin.  Close  investigation  of  the  early  condition 
of  the  patient  would  most  readily  determine  a  correct  diagnosis. 

Mr.  Erichsen,  in  his  Avork  on  the  Science  and  Art  of  Surgery, 
18C4,  p.  746,  Loud.  Ed.  4,  says :  "  Chronic  Rheumatic  Arthritis : 
It  commonly  affects  the  hip.  I  have  met  with  cases  of  disease  of 
this  joint  presenting  all  the  character  of  this  afifection  during  life, 
though,  as  there  has  been  no  opportunity  of  examining  the  state  of 
the  parts  after  death,  it  is  impossible  to  speak  positively  as  to  the 
true  nature  of  the  disease.  Chronic  rheumatic  arthritis  is  an  active 
disease  of  the  bones  and  fibrous  expansions  about  the  joints;  it  is 
especially  characterized  by  considerable  increase  in  the  size,  and  by 
alteration,  of  the  shape  of  the  osseous  structure,  which  becomes 
porous  in  some  parts,  porcelaneous  in  others,  by  thickening  of  the 
fibrous  capsule  of  the  joint  with  deposition  of  masses  or  plates  of 
bone  in  it,  and  ultimate  destruction  of  the  cartilages  and  synovial 
membranes.  The  suffering  is  considerable;  the  disease  greatly 
cripples  the  utility  of  the  joint,  at  last  produces  incomplete  anchy- 
losis of  it,  and  is  incurable."  This  greatly  simulates  hip  disease  of 
the  ordinary  kind  in  its  incipient  stage,  except  that  it  is  a  dull,  con- 
stant, aching  pain,  attacking  persons  about  the  age  of  puberty,  and 
that  have  been  subject  to  rheumatic  seizures  during  changes  of 
weather,  and  not  the  result  of  a  fall  or  bruise  about  the  hips. 
From  a  careful  investigation  of  the  history  of  the  case  a  true  diag- 
nosis is  obtained. 

*  On  Joint  Diseases,  1867,  p.  124,  Lond.  Ed. 


312  Or  thop^dia  . 

Neuralgia  of  the  sacro-iliac  joint  —  This  disease  was  first  noticed 
by  Bayer  and  Chelins,  and  since  by  ISTelaton  and  Erichsen.  The 
latter  Avriter  remarks  that  '•'  the  disease  may  be  confoiiuded  with 
some  of  the  varieties  of  coxalgia,  and  that  it  is  essentially  a  very 
chronic  affection,  lasting-  for  months  and  years.  The  disease 
appears  to  be  strnmous  in  its  origin,  partaking  of  the  nature  and 
ordinary  character  of ''white  swelling."  I  have  never  seen  it  iu 
young  childreu,  and  in  all  the  cases  which  form  the  basis  of  these 
observations  it  has  occurred  in  young  adults  from  14  to  30  years 
old.  The  exciting  causes  of  this  disease  are  obscure.  I  have  not 
been  able  to  trace  it  to  a  bloAV  or  injury  in  any  of  tlie  cases  that 
have  been  under  my  care,  although  there  can  be  very  little  doubt 
that  such  causes  might  excite  it.  We  have  had  cases  of  this  ailment 
to  treat,  as  we  believe  from  the  indications,  and  in  one  case,  a  boy 
ot  eleven  years  of  age  who  died  after  two  years  of  great  suffering, 
and  the  only  relief  afforded  him  was  from  increased  doses  of  mor- 
phine from  time  to  time.  His  parents  refused  an  examination  after 
his  death.  The  appearance  of  the  hip  in  the  early  stage  was  of 
a  more  than  ordinary  flattening  or  laxity  of  the  glutei  muscles,  and 
the  child  would  place  his  finger  upon  the  sacro-iliac  symphysis 
when  asked  to  touch  the  part  that  pained  him.  The  limb  was 
longer  than  its  fellow  when  first  examined,  and  became  attenuated 
to  mere  skin  and  bone.  The  hip  was  not  so  largely  swelled  in  the 
anterior  region  as  in  that  of  ordinary  hip  disease.  There  were  no 
perceptible  changes  of  the  trochanter  major  throughout  the  pro- 
gress of  the  disease,  yet  there  was  a  decided  rotation  of  the  toes  in- 
ward. An  abscess  opened  upon  the  ilium  near  the  upper  junction 
of  the  sacro  iliac  symphysis,  and  discharged  a  most  fetid  sanies 
and  purulent  matter,  but  not  an  excessive  quantity.  And,  in  all 
the  cases  that  we  have  diagnosed  as  this  ailment,  the  patients  have 
never  located  the  pain  at  the  knee.  Pain  in  the  limb,  thigh,  and 
below  the  knee  at  times,  and  not  of  any  great  duration  were  com- 
plained of,  but  the  pain  was,  mainly,  confined  to  the  location  of  the 
disease. 

The  difference  of  indications  tending  to  a  correct  diagnosis  of 
each  ailment  are  as  follows: 

a.  In  coxalgia  the  patient  suffers  most  severely  when  pressure  is 
made  posteriorly  and  above  the  trochanter,  and  in  the  depression 
beneath  the  prominence,  or  compression  against  the  anterior  part 
of  the  hip  joint  through  the  pectinens    muscle. 


Diseases  of  the  Joints.  313 

In  the  sacro-iliac  disease  no  pain  is  experienced  on  pressure  in 
these  situations. 

h.  In  coxalgia,  abduction  and  rotation  outwards,  and  pressure  of 
the  head  of  the  thigh  bone  into  the  acetabulum  gives  pain  and  suf- 
fering to  the  patient. 

In  sacro-iliac  diseases  these  movements  give  no  pain  if  the  pelvis 
is  supported  by  an  assistant. 

c.  In  coxalgia,  in  the  advanced  stages,  a  decided  shortening  of 
the  limb  exists. 

In  sacro-iliac  disease  no  shortening  ensues  throughout  the  ail- 
ment. 

These  indications  will  designate  coxalgia  from  all  simulating  ail- 
ments, if  carefully  observed. 

The  patient  having  been  relieved  from  the  active  diseased  condi- 
tion of  the  joint,  but  with  a  resulting  angular  deformity,  surgical 
aid  often  affords  great  relief. 

In  cases  of  ligamentous  adhesions,  involving  the  surrounding 
tissues  of  the  impaired  joint,  the  limb  may  be  restored  to  normal 
usefulness  by  the  application  of  sufficient  force  to  free  the  joint. 
This  treatment,  when  skillfully  performed,  is  seldom  attended  with 
unfavorable  results. 

Prof.  Frank  H.  Hamilton,  A.M.,  M.D.,  LL.D.,  Consulting  Sui'- 
geon  to  the  Hospital  for  the  Relief  of  the  Ruptured  and  Crippled, 
and  one  of  our  most  distinguished  surgeons,  in  his  elaborate  work 
on  the  "Principles  and  Practice  of  Surgery,"  page  413,  advises  that 
when  the  superficial  tendons  and  muscles  do  not  yield  readily  to 
the  extending  force,  that  they  be  cut  subcutaneously  rather  than 
the  chances  be  taken  of  tearing  them  asunder  by  greater  violence. 

In  other  forms  of  angular  deformity,  segments  of  loose  bone 
have  been  removed  and  the  limbs  straightened. 


CHAPTER  XIII. 

ADVANCING  DISEASES  OF  THE  BONES. 

Various  causes  of  Necrosis.  —  Traumatic  Necrosis.  —  Diaguostic-liistory. — 
Expectant  course  of  treatment.  —  Periostitis.  —  Instances  among  patients  in 
Hospital  for  Relief  of  the  Ruptured  and  Crippled.  —  Young  more  susceptible 
than  adults.  — Seldom  confined  to  one  bone.  — Violence  done  to  the  recuperative 
processes  by  sawing,  etc.,  often  arrest  the  normal  tendency  to  cure.  —  Acute  sub- 
periosteal inflammation. — Seven  years'  experience  in  Baltimore  General  Dispen- 
sary.—  Objection  offered  to  expectant  treatment. —  Synovitis  OF  the  Knee 
Joint. — "  White  Swelling."  —  Premonitory  symptoms.  —  Inflammation  of  the 
two  bursae.  —  But  two  structures  in  composition  of  joint  subject  to  inflamma- 
tion.—  Fully  80  per  cent  of  cases  synovitis  affect  the  knee-joint.  — Acute  and 
chronic  synovitis.  —  Formation  of  abscesses.  —  Erichsen  on  synovitis.  —  Treat- 
ment.—  Apparatus  —  Anchylosis,  in  its  various  conditions. —  Proper  diag- 
nosis of  vital  importance,  to  distinguish  between  true  and  false  anchylosis. — 
Distinguishing  features  in  true  anchylosis.  —  False  anchylosis  frequently  the 
result  of  disease  of  the  articulation.  —  The  Gonyometer.  —  Sub-luxation  of  the 
Joint.  —  Treatment.  —  The  Roller.  —  Holmes  Coote  and  Dr.  Hodges  on  the 
restoration  of  the  limb  to  its  perpendicular  condition.  —  Resection.  —  Illustra- 
tive Cases.  —  Result  of  1,326  cases  treated  in  Hospital  for  Relief  of  Ruptured 
and  Crippled.  —  Anchylosis  op  Joints  and  Treatment.  —  Locomotive 
apparatus  invented  by  Stephen  W.  Smith's  Sons,  of  New  York  City.  —  Swing 
manufactured  by  E.  L.  Horman.  —  Floating  Cartilages  in  Joints. — 
Erichsen's  method  of  treatment.  —  The  Knee  Bandage.  —  Caries  op  the 
Vertebra.  —  Diagnosis.  —  Dyspnoea  an  early  symptom.  —  Kyphosis,  or 
Posterior  Curvature  op  the  Spine.  —  Diagnosis  of  the  several  stages. — 
Symptoms  of  adults  vary  from  those  of  children.  —  Abscesses  arising  from 
Caries  of  the  Spine. —  Prognosis  more  favorable  in  children  than  in  adults. — 
Caries  of  the  cervical  vertebrae.  —  Causes  and  seat  of  the  disease.  —  Motor 
paralysis  a  concomitant  of  caries  of  the  cervical  vertebrae.  —  Treatment  of 
Caries  op  the  Spine.  —  Social  enjoyment,  and  amusement,  a  potent  remedial 
influence,  as  exemplified  at  the  Hospital  for  Relief  of  Ru].itured  and  Crippled. 
—  Children  should  not  be  confined  to  bed.  —  General  Treatment.  —  Diet. — 
Mejhanical  Appliances.  —  Holmes  Coote  on  Remedies  for  Caries  of  the 
Spine. — Medical  Treatment.  —  Preventive  means  to  be  adopted.  —  Unskil- 
ful treatment  induces  paralysis.  —  Exposure  of  charlatans. —  Advanced  stages 
of  caries  of  the  spine  the  least  amenable  to  cure  of  all  bone  diseases.  — 
Physical  signs  of  formation  of  spinal  abscesses.  —  Objection  to  removal  by- 
use  of  knife,  trocar  or  caustic.  —  Drs.  Holmes  and  Erichsen  on  Treatment.  — 
Oar  method  of    treatment. 


Diseases  of  the  Bones.  315 

Various  causes  may  tend  to  the  arrest  of  nutrition  in  a  limited 
portion  of  bone,  which,  it  may  be  said,  destroys  the  life  of  that 
affected  portion.  When,  as  a  foreign  substance,  the  indurated  bone 
becomes  an  irritant,  it  induces  an  inflammation  that  results  in  an 
exfoliation  of  the  dead  bone,  and  an  effort,  as  it  were,  to  cast'  it  off, 
which,  for  a  time,  is  impossible  without  surgical  interferenLx:,  If 
an  injury  is  done  the  bone,  as  is  most  commonly  the  case,  and  puru- 
lent periostitis  ensues,  which  is  in  proportion  to  the  depravity  of  the 
constitution,  we  tlien  have  traumatic  tiecrosis — pus  having  formed 
between  the  periosteum  and  the  bone.  Under  this  condition,  the 
nutrient  vessels  are  either  ruptured  or  compressed  to  the  arrest  of 
supply,  and  the  result  is  necrosis.  In  more  healthy  subjects,  necro- 
sis will  not  always  follow  purulent  periostitis;  the  reparative  force 
being  equal  to  the  emergency  in  removing  the  irritant  cause,  and 
the  restoration  of  the  nutrient  function  that  had  been  partially 
arrested  by  the  violence  done  the  parts.  But,  if  this  favorable  con- 
dition does  not  exist,  sequestering  inflammation  progresses  to  the 
conversion  of  the  periosteum  into  a  pyogenic  membrane,  that  pro- 
tects the  organism  against  its  own  secreting  product.  In  the  bone, 
there  develops  a  rarefying  ostitis,  whose  oflQce  it  is  to  protect  the 
organism  by  a  layer  of  granulation  tissue  surrounding  the  dead 
part. 

This  rarefying  ostitis  is  nourished  from  the  medulla,  and  reaches 
as  far  into  the  compact  substance  as  its  vascular  tracks  have 
remained  open  and  in  circulation.  There  are  cases  where  it  develops 
u\)on  the  outer  surface,  where  the  Haversian  canals  dilate,  and  the 
tissues  of  granulation  spring  up  in  numberless  vascular  villosities 
and  unite  into  a  continuous  layer  which  then  connects  with  the  ele- 
vated periosteum  into  an  abscess  membrane,  inclosed  all  around. 
IVlust  frequently,  however,  the  outer  layers  of  the  compact  substance 
having  been  too  long  deprived  of  circulation,  and  the  exchange  of 
material,  that  their  revitalization  could  be  possible  by  the  medulla; 
and  the  rarefying  ostitis  appears  as  a  sequestering  inflammation 
which  separates  the  lamellae  that  have  perished,  and  ends  in  pus 
which  fills  the  abscess  cavity.  The  dead  bone  is  denominated 
sequestrum  ;  and  the  rarefying  ostitis  that  separates  it,  demarcation. 
The  demarcation  may  occupy  months  and  years. 

During  this  time  the  suppuration  continues  uninterruptedly; 
the  elevated  periosteum,  however,  again  returns  to  its  ossifying 
capacity,  and  forms  under  the  pyogenic  surface  a  layer  of  new 


316  Orthop^^dia. 

osseous  tissue  which,  in  time,  may  attain  a  very  considerable  thick- 
ness. The  bony  capsule  (called  coffin),  thus  produced,  lodges  more 
or  less  loosened  sequestrum  in  its  interior.  The  adjacent  attached 
periosteum  also  participates  by  ossifying  periostitis.  For  a  distance 
of  several  inches  upwards  and  downwards,  osteophytes  and  exostoses 
arise  in  varying  form  and  number.  All  these  phenomena  of  inflam- 
mation extending  to  some  distance,  disappear  as  soon  as  the  seques- 
trum is  successfully  removed.  Even  the  bony  capsule  diminishes, 
and,  by  the  obliteration  of  the  cavity  of  tlie  abscess,  becomes 
attached  to  the  surface  of  the  bone,  the  exostosis  disappears,  and 
the  bone  assumes  its  normal  form.*  The  health  of  the  patient  being 
vigorous,  or  improved  by  favorable  hygienic  influence,  tends  to  the 
disposition  of  the  sequestrum;  if  in  large  portions  —  and  more 
especially  in  young  subjects  —  it  is  reduced  by  the  process  of  absorp- 
tion to  spiculge  that  become  displaced,  and  their  thinned  points 
penetrate  the  surrounding  soft  tissues,  exciting  in  them  inflamma- 
tion and  suppuration  that  results  in  an  opening  from  which  the 
irritant  spicula  escapes,  or  can  be  readily  removed.  This  is  known 
as  the  expectant  course  of  restoration  to  a  normal  condition,  and 
usually  results  favorably  even  in  delicate  constitutions  when  a  care- 
fully enforced  regime  is  made  available  by  treatment,  as  in  a  hos- 
pital especially  designed  for  the  treatm.ent  of  this  class  of  patients. 

Periostitis  in  children,  tending  to  necrosis,  involves,  more  or  less, 
all  the  long  bones ;  as  we  have  now  in  the  Hospital  for  the  Eelief 
of  the  Euptured  and  Crippled  a  girl  of  fourteen  years  of  age  having 
necrosis  of  the  tibia,  brachii,  and  both  clavicles,  and  an  out  patient, 
a  boy  of  about  the  same  age,  having  necrosis  of  the  femur,  ulna, 
and  one  clavicle  —  and  others,  in  progress  of  cure.  This  pathologi- 
cal condition  is  one  of  the  constitutional  ailments  presenting 
pathognomic  indications  of  scorbutus;  there  being  no  evidence  of 
tubercular  deposits,  such  as  enlarged  glands,  or,  primarily,  enlarge- 
ment of  cancellated  bone. 

This  is  an  ailment  observable  in  young  persons  from  the  age  of 
eleven  to  fourteen,  and  never  involving  so  many  of  the  bones  at  the 
same  time  in  adults.  When  acute  it  runs  its  course  most  rapidly, 
and  is  mostly  induced  by  injury  in  a  scorbutic  diathesis. 

The  inception  of  the  ailment  is  not  always  from  accidental 
lnj.ury,  but  an  idiopathic  indication  tending  to  spontaneous,  slowly 
increasing,  periosteal  inflammation  apparent  over  the  shafts  of  bones 


*  "Text-book  of  Pathological  Histology,  by  Dr.  Edward  Rindfleisch,  p.  581  —  1872. 


Diseases  of  the  Bones.  317 

and  attended  at  times  with  much  sufiering,  more  especially  in  the 
early  stage  of  the  ailment;  the  patient  being  much  reduced  in 
strength,  with  decided  constitutional  cachexia,  indicating  serious 
encroachment  of  disease.  It  is  but  seldom  confined  to  one  bone, 
And  ordinarily  limited  to  the  diaphysis,  involving  the  joint  only 
when  extending  the  entire  length  of  the  bone,  and,  even  then,  but 
seldom  impairs  the  integrity  of  the  joint.  Inflammation  usually 
extends  along  the  entire  shaft  of  the  alfected  bone,  tending  to 
extensive  tumefaction,  and  induration  of  the  surrounding  tissues. 
After  a  time,  small  abscesses  form ;  and,  when  open,  expose  exten- 
sive sinuses  and  denuded  bone.  But  the  less  probing  and  meddling 
with  the  diseased  bone,  other  than  when  a  spicula  presents  free  and 
projecting,  to  remove  it,  the  greater  the  success  that  will  be  attained 
in  saving  the  life  and  limb  of  the  patient. 

Much  experience  in  the  treatment  of  this  ailment  will  determine 
the  expectant  treatment  to  be  the  most  successful.  The  greatest 
effort  should  be  made  to  improve  the  health  by  the  enforcement  of 
-careful  hygiene  and  alterative  tonics,  careful  attention  to  the 
digestive  functions,  and  patient  waiting  for  the  liberated  spiculae  in 
small  pieces  to  be  thrown  off  from  time  to  time.  This  will  result 
most  favorably  to  the  patient.  The  violence  done  to  the  recupera- 
tive processes  by  splitting,  sawing,  and  chiseling,  for  the  purpose  of 
removing  the  sequestrum  of  decaying  bone,  often  arrests  the  nor- 
mal tendency  to  a  cure,  and  impairs  vitality  to  the  extent  of  a  neces- 
sity for  amputation  which  seldom  saves  the  patient's  life.  Much 
probing  and  handling  tends  to  like  results  when  the  patient  is  in 
the  condition  of  health  that  might  result  favorably  under  the 
•expectant  treatment.  This  conclusion  has  not  been  arrived  at 
without  experience,  having  spent  seven  years  in  the  Baltimore 
Greneral  Dispensary,  practicing  and  witnessing  the  practice  of  others 
in  the  removal  of  necrosed  bone,  in  many  cases  by  efforts  made 
when  the  sequestra  appeared  to  be  free  of  attachment,  to  the  loss  of 
the  limb  in  some,  and  of  the  life  of  the  patient  in  others.  Like 
■cases  were,  from  the  expectant  treatment,  as  subsequently  practiced, 
.attended  with  the  most  favorable  results. 

In  the  acute  subperiosteal  inflammation  and  necrosis  of  the  bone, 
this  being  more  of  a  local  lesion  and  active  destruction  of  the  limb, 
indications  of  pysemia  supervening,  demands  more  decided  relief, 
and  amputation  as  an  imperative  treatment.  These  cases  are 
mostly  attended  with  decided  constitutional  derangement,  as  that  of 


318  Obthop^bia. 

prostration,  great  pain,  rapid  pulse,  foul   tongue,  frequent  rigors, 
and  delirium. 

The  objection  offered  to  the  expectant  treatment,  in  the  chronic 
condition  of  the  patient,  is  that  of  long  confinement,  and  as  by  some^ 
to  the  bed.  Now  the  latter  is  objectionable  and  not  required. 
Judicious  treatment  consists  in  having  the  patient  exposed  to  fresh 
air,  social  entertainment,  and,  at  the  same  time,  agreeable  employ- 
ment. And  of  children,  the  attainment  of  an  education,  subject  to 
careful  limitation,  thus  avoiding  the  tedium  of  confinement.  These 
are  the  rational  means  of  restoring  a  recuperative  condition  of  the 
system,  tending  to  the  exfoliation  and  absorption  of  the  non-vital- 
ized bone,  resulting  in  disintegration,  to  that  of  spicula  that  can 
be  removed  without  injury  to  the  ossifying  process  —  the  surround- 
ing tissues  being  readily  restored. 

STXOYITIS    OE   THE   KXEE   JOIXT. 

This  disease  of  the  knee  is  commonly  known  as  "'white  swelling." 
In  this,  as  in  all  chronic  inflammations  tending  to  the  destruction  ol 
joints  (and  all  joints  are  subject  to  the  invasion,  we  believe)  when  there 
is  a  constitutional  predisposition.  Bruises,  lacerations,  and  incised 
wounds,  heal  with  limited  impairment  of  the  joint  in  normally  con- 
ditioned persons,  whilst  the  slightest  bruise  will  induce  a  slow,  pro- 
gressive induration  of  a  joint  in  those  predisposed  to  this  tendency  , 
and  the  invasion  not  being  superficial,  is  tinattended  with  redness, 
as  in  ordinary  inflammations ;  there  appearing  to  be,  rather,  a  tor- 
pidity of  the  superficial  tissues  that  in  time  becomes  implicated  and 
attended  with  redness  and  dissolution  in  parts,  permitting  the  mor- 
bid matter  to  escape  by  sinuses  from  the  depth  of  the  diseased  joint.. 

Deep  seated  pain  in  the  knee  attended  with  slight  chill  and  an 
increase  of  the  circulation,  indicating  one  or  two  degrees  increase 
in  temperature  above  that  of  the  other  limb,  demands  prompt  treat- 
ment, which  will,  in  a  majority  of  cases,  arrest  the  supervening- 
tendency  ;  as  that  of  change  of  form  ;  a  uniform  surface  quite  tense 
and  tumaceous;  the  patella  seeming  to  float  in  the  great  increase  of 
synovial  fluid,  which  can  be  made  to  fluctuate  from  side  to  side  of 
the  knee.  This  enlargement  indicates  fluid  passing  up  between  the 
femur  and  extensor  muscles,  tending  to  a  fulness  of  the  popliteal 
space,  and,  conjoined  Avith  this  apparent  change,  is  semiflexion  of 
about  120°. 

Inflammation  of  the  two  bursse  somewhat  simulates  synovitis  of 


Diseases  of  the  Bones.  319 

the  kuee-joiut ;  the  one  below  the  patella,  and  a  small  one,  when  in 
a  normal  condition,  above.  When  these  are  inflamed  they  are 
circumscribed  and  prominent,  rising  above  the  patella,  and  not 
involving  the  entire  region  of  the  knee,  nor  is  the  disease  as  painful 
as  synovitis  of  the  knee-joint.  These  are  the  most  commonly 
affected.  Those  under  the  quadriceps  extensor  cruris  and  the  ten- 
don of  the  semi-membranosus  only  become  involved  when  the  sur- 
rounding tissues  are  decidedly  diseased.  These  bursas,  when  in  a 
normal  condition,  supply  the  joint  with  lubricating  fluid,  com- 
municating directly  with  the  joint,  and  it  is  only  remaxkable  that 
they  do  not  become  largely  implicated  in  the  incipient  stage  of  syno- 
vitis of  the  knee  joints. 

The  knee  has,  of  all  the  joints,  the  most  extensive  synovial  mem- 
brane, and  from  its  exposed  position,  is  the  most  subject  to  violence, 
the  injurious  effects  of  cold,  and  constitutional  irritation.  There 
are  but  two  structures  entering  into  the  composition  of  the  joint 
subject  to  primary  inflammations  :  the  synovial  membrane  and  the 
cancellous  tissue  of  the  articular  extremities  of  the  bones.  Of  syno- 
vitis it  is  stated  that  80  per  cent  of  all  cases  affect  the  knee  joint.* 
It  is  subject  to  acute  and  chronic  inflammations  of  the  synovial 
membrane.  In  the  former  the  symptoms  are  more  severe  and 
attended  with  more  general  disturbance  of  the  system.  In  the 
chronic  form  there  is  less  disturbance,  the  joint  less  distended,  and 
less  pain.  Cases  often  present  for  treatment  in  which  the  patient 
states  that  there  is  no  pain ;  yet,  the  leg  is  flexed  and  the  synovial 
membrane  thickened,  indicating  the  want  of  treatment. 

Abscesses  forming  about  the  knee,  may  be  recognized  by  their 
form  and  redness,  and  limited  fluctuation.  They  should  be  opened 
early,  as  they  might  involve  the  interior  of  the  joint.  Being  re- 
lieved of  pus,  they  are  most  readily  subdued;  having,  however,  a 
tendency  to  repetition,  if  attention  is  not  given  the  geuei'al  health 
of  the  patient.  The  opening  of  these  abscesses  demands  special  dis- 
crimination, as  the  joint  may  be  penetrated,  to  the  great  injury  of 
the  patient;  there  being  an  irregular  distending  point  of  the  dis- 
eased tissues  of  the  joint  that  may  be  mistaken  for  a  circumscribed 
abscess. 

The  external  tissues  surrounding  the  knee  joint  in  this  ailment 
usually  become  infiltrated  with  fatty  and  plastic  matter,  tending  to 
gelatinous  infiltration  and    suppuration.      The   cartilages   become 

*  Holmes  Coote,  on  Joint  Disease,  p.  129. 


320 


Orthop^dia. 


softened  and  changed  in  appearance,  the  synovial  membrane  is 
removed  in  parts  and  replaced  by  large  quantities  of  semi-trans- 
parent gelatinous  fatty  deposit,  or  pulpy  grey  and  brownish  fibro- 
cellular  material.  The  ligaments  become  inflamed,  softened,  and 
destroyed,  being  converted  into  somewhat  similar  materials ;  and 
the  interior  of  the  joint  is  filled  with  a  purulent  looking  synovial 
fluid,  thin  and  yellow,  containing  a  quantity  of  fatty  matter. 
Important  changes  take  place  in  the  articulations  of  the  bones ; 
they  become  enlarged,  the  cancellated  cells  filled  with  bloody,  fatty, 
serous  fluid,  and  the  bone  so  softened  as  to  be  readily  cut  with  a 
knife,  and  being  so  filled  with  fat,  presents,  when  cut,  a  homogeneous 
surface  resembling  that  of  healthy  bone.  Mr.  Erichsen,  in  remark- 
ing on  this  subject,  says :  "From  this  it  would  appear  that  the  prin- 
cipal changes  that  take  place  in  a  joint  aflected  with  white-swelling 
consists  in  a  kind  of  fatty  degeneration  of  tlie  tissues  that  enter 
into  th-e  formation  of  the  articulation  associated  with  an  unhealthy 
strumous  inflammation  of  the  parts,  a,nd  in  the  consequent  deposi- 
tion of  considerable  quantities  of  semi-transparent  and  lowly 
organized  plastic  matter,  which  in  its  turn  has  a  tendency  to 
undergo  the  same  structural  change,  or  to  run  into  unhealthy  sup- 
puration." 

Treatment  of  synovitis  in  the  knee  joint  applies  equally  to  all 
other  joints  similarly  affected.  The  first  object  is,  if  possible,  to 
arrest  the  tendency  to  suppuration.  Alterative  tonics,  and  an 
enforced  hygiene,  blistering  and  poulticing;  and  on  the  denuded 
surface  sprinkling  a  small  quantity  of  starch  and  morphia,  keeping 
Fig.  116  ^'^®   knee   perfectly  supported,  and   the   patient 

out  of  bed  and  agreeably  entertained.  The  last 
is  of  much  importance.  Brooding  over  his  con- 
dition greatly  impairs  the  general  health  of  the 
patient,  to  the  increase  of  the  local  derangement. 
The  knee  can  be  most  readily  supported  with 
the  light  steel  frame  which  we  devised  for  the 
purpose  several  years  since,  and  known  as  the 
knee  support. 

Two  laterally  curved  steel  bars  secured  to 
broad  belts  of  sheet  steel  by  means  of  rivets, 
admitting  of  free  movement  for  adaptation  to 
the  limb.  The  belts  are  suitably  padded,  and 
broad  straps  are  affixed  to  encircle   the  limb 


Diseases  of  the  Bones. 


321 


above  and  below  the  joint,  and  with  a  pliant  roller  carefully  applied. 
This  seci^res  rest,  and  admits  of  the  dressings. 

After  blistering  and  poulticing,  to  the  relief  of  severe  pain  and 
tenderness,  cloths  saturated  with  the  lotion  of  animon.  chlor.  and 
plumbi  acetas  described  in  the  treatment  of  hip  disease  should  be 
applied  and  kept  constantly  wet  with  the  solution  until  the  tem- 
perature is  reduced  to  a  normal  condition  and  so  maintained  with 
water  dressings.  The  following  liniment  may  then  be  applied,  and 
if  a  more  extended  support  is  desired,  the  following  form  (Fig  117) 
may  be  made  available  as  answering  a  better  purpose  for  walking 
when  the  patient  can  be  permitted  to  do  so. 


5. 


Fig.  117. 


Lin.  sapo.  camph |  vi 

Tr.  belladonnas 

"    iodini,  fort,  aa 31 

01.  cajeput 3  i 

^. 
Ft.  emb. 

This  embrocation  should  be  ajjplied 
once  in  twenty-four  hours,  and  the  knee 
firmly  bandaged  with  a  flannel  roller,  or 
a  thick  application  of  cotton  wadding, 
and  over  this  a  lacing  of  firm  woven  fab- 
ric in  form  of  the  knee  bandage.  The 
bowels  should  be  kept  quite  free  with  an 
•occasional  dose  of  calomel  and  jalap  or 
scammony,  comp.  ext.  of  jalap  or  colocynth.  When  not  under 
the  influence  of  the  purgative,  and  reduced  in  strength  and  gen- 
eral development,  give  an  ordinary  teaspoonful  of  cod-liver  oil 
an  hour  after  meals  and  from  eight  to  ten  minims  of  syr.  ferri  iod., 
night  and  morning.  To  patients,  rotund  in  form  and  seeming  full 
in  habit,  give  the  following  : 

Hydrarg.  bichlor ; . . . .     grs.  ii 

Tr.  cinchon.  comp 3  vi 


Ft.  mist. 
Of  this  give  a  teaspoonful  three  times  a  day ;    the  iron  and  oil 


322 


Orthop^dia. 


Fif).  118. 


being  inadmissible  to  such  patients.  The  inflammation  having 
been  subdued,  and  the  patient  disposed  to  take  exercise  with  a 
crutch  or  chair  (the  latter  preferable),  the  straight  upright  brace 
(Fig.  117.)  should  be  secured  to  the  limb  by  the  roller.     See  Fig.  118. 

Fig.  118,  A,  the  roller,  a  few  turns  or 
so  having  been  taken  within  the  bars  and 
over  the  knee,  thus  tending  to  bring  the 
knee  within  the  bars  extending  the  limb, 
and  then  encircling  the  limb.  B,  a, 
gaiter  applied  over  the  brace,  for  walking. 
Tliis  serves  as  a  protection  against 
unfavorable  position,  in  case  of  slipping 
or  getting  a  fall,  to  the  injury  of  the 
knee. 

In  this  stage  of  the  ailment  there  is 
thickening  and  stiffness  of  the  joint, 
and  an  effort  must  be  made  to  restore 
flexibility  of  the  articulation  by  gentle 
manipulation,  always  avoiding  painful 
extension  by  applying  the  roller  too 
firmly  about  the  joint.  The  forcible 
extension  of  the  joint  has  in  many  instances,  after  much  suffering,, 
compromised  the  patient's  life. 

Mr.  Erichsen  truly  states,  in  his  work  on  Surgery,  that  "''the 

swelling  and  puffiness    that   are   left,   together   with    the  debility 

dependent  upon  relaxation  of  the  ligaments,  are  perhaps  best  reme- 

Fig.  119.  tliecl  by   the  use  of    Scott's  strapping;   but 

pressure   should   not  be  applied  so  long  as 

there    is    evidence   of    active    inflammation 

going  on  in  the  articulation,  which  it  would 

certainly  increase." 

The  limb,  even  in  the  early  stage  of  synovi- 
tic  invasion  of  the  knee,  is  in  some  cases 
flexed  to  a  right  angle,  and  the  tendons  under 
the  knee  very  tense.  This  we  never  attempt 
to  control,  when  such  attempts  give  the 
slightest  pain.  Support  is  essential  to  avoid 
undue  motion,  and  if  tenseness  exists,  the 
knee  should  be  bathed  for  fifteen  or  twenty 
minutes  in  warm  water  holding  in  solution 


Diseases  of  the  Bones. 


323 


half  a  drachm  of  Potass.  Garb,  to  the  quart,  then  dried,  and  the 
following  lotion  applied  night  and  morning,  and  a  brace  as  shown 
in  Fig.  119. 


Fig.  120. 


^- 


Fig.  121. 


Tr. 
01. 


bellad. 
olivse. . 


M. 


Et.   embro. 


The  pressure  should  be,   at 

each   dressing,  carefully    gov- 
erned by  the  pain  induced. 

This  brace  serves  an  admirable 

purpose     Avhere    extension    is 

applicable  to   the  overcoming 

of  angular  contraction  of  the 

knee  or  elbow  in  cases  relieved 
of    all   inflammation    and  in  a  flexed  condition,  as  seen   in  Pigs. 
120  and  121. 

ANCHYLOSIS,  IN"   ITS   VARIOUS    CONDITIONS, 

Of  all  the  joints  in  the  human  frame,  the  knee  is  the  most 
often  found  to  be  anchylosed  in  various  degrees.  The  knee  con- 
sists largely  of  fibrous  tissue  thinly  covered  compared  to  other 
joints,  and  more  exposed  to  injury.  Inflammation  readily  follows 
the  injuries  in  degree  to  the  force  of  violence,  and  a  scrofulous  dia- 
thesis of  the  patient,  which  results  in  contraction  and  deformity,  if 
not  relieved  in  the  incipient  stage  of  the  increasing  excitement. 
When  not  arrested,  deep-seated  pain  and  great  distension  of  the 
joint  follows  without  redness,  but  with  decided  increase  of  temper- 
ature. After  much  suffering,  anchylosis  supervenes  by  osseous 
deposit,  partial  or  complete ;  or,  we  may  have  what  is  most  common, 
partial  or  membranous  stiffening  of  the  knee. 

A  proper  diagnosis  of  the  condition  of  the  knee,  under  these  cir- 
cumstances, is  of  great  importance  —  to  distinguish  true  from  false 
anchylosis.  Cases  frequently  present  after  eminent  practitioners  in 
surgery  have  given  their  opinion,  and  as  to  what  they  have  stated, 
having  knowledge  of  the  history  of  the  ailment,  we  are  often  not 
correctly  informed.  Our  judgment  in  such  cases  is  alone  to  be 
founded  on  our  experience  from  careful  observation  in  practice. 
To  attempt  a  long,  tedious  course  of  treatment  and  fail  to  straighten 


324  Obthop^bta. 

the  contracted  leg  (as  all  cases  of  anchylosis  are  slow  in  being 
redressed),  the  surgeon  seriously  compromises  his  professional 
status  by  incurring  the  displeasure  of  the  patient,  and  friends  who 
had  been  advised  of  the  incurable  condition  of  the  limb,  but  ventured 
upon  another's  supposed  superior  judgment.  This  impairs  confi- 
dence in  others  who  might  be  readily  cured  by  skilful  treatment. 

The  straight  condition  of  the  leg  from  anchylosis  of  the  knee, 
presents  serious  inconvenience  to  the  patient,  inducing  him  to  seek 
advice  from  the  most  skilful  surgeon,  and  if  discouraged  as  to  the 
possibility  of  obtaining  relief,  intrust  their  limb  to  adventurous 
treatment  in  hope  of  finding  relief,  and  often  pass  through  the 
ordeal  of  much  suffering  without  the  least  possible  relief;  yet  many 
of  these  cases  thus  conditioned  are,  by  practical  skill,  curable.  False 
anchylosis  is  exceedingly  deceptive,  and  cases  often  pronounced  in- 
■curable  by  eminent  surgeons  in  general  practice,  are  subsequently 
oured  by  those  having  more  practical  skill  in  the  manipulation  of 
anchylosed  limbs. 

The  leg,  v/hen  straight  from  anchylosis,  commonly  presents 
slight  rotation  outwards  —  the  toes  everted,  which,  in  the  act  of 
walking,  the  foot  more  easily  avoids  inequalities  on  the  surface  of 
the  ground.  This  condition  of  the  knee  is  often  the  result  of  imjDer- 
fect  treatment  of  anchylosis,  violent  or  gradual  extension  having 
■  been  accomplished  without  careful  attention  to  that  of  giving  free 
motion  to  the  joint.  The  limb  may  appear  very  rigid,  and  yet  only 
by  the  attachment  of  the  fibrous  tissues,  being  in  a  curable  condi- 
tion ;  and  most  commonly  so  when  carefully  straightened.  ITuder 
these  circumstances  a  favorable  prognosis  may  be  given  —  the  limb 
having  yielded  to  extension  that  placed  it  in  the  straightened  posi- 
tion without  having  excited  inflammation  to  any  great  extent,  only 
sufficient  to  give  a  fixedness  to  the  joint,  which  is  in  quite  a  favor- 
able coiidition  for  the  restoration  of  flexion  and  voluntary  move- 
ment. 

In  all  cases  it  is  necessary  to  consider  carefully  the  probable 
nature  of  the  impediment  to  motion  in  the  joint,  by  ascertaining 
whether  it  arises  from  adhesions  resulting  from  effusion  of  lymph 
in  the  articular  tissues,  or  bands  of  adventitious  matter,  the  product 
of  cicatricial  sinuses,  or  from  membranous  and  calcerous  adhesions 
of  the  articular  surfaces.  To  determine  the  existence  of  mobility 
careful  investigation  is  essential,  as  if  very  slight  movement  and 
positively  determined  —  the  patient's  health  being  good  —  a  favor- 


Diseases  of  the  Bones. 


325 


able  prognosis  can  be  given,  and  if  successful  in  obtaining  mobility 
to  tl;ie  extent  of  a  few  degrees  it  will  greatly  favor  the  patient  and 
compensate  the  surgeon  for  his  efforts.  Before,  however,  attempt- 
ing to  relieve  the  fixed  condition  of  the  joint,  ascertain  the  patient's 
condition  of  health,  and,  if  possible,  the  extent  of  inflammation 
that  has  existed,  as  also  its  termination,  by  resolution  or  destruction 
of  the  articular  tissues  within  the  joint.  The  history  of  the  case 
enlightens  the  surgeon  considerably  as  to  the  extent  of  relief  to  be 
afforded  the  patient.  This  is  not  always  readily  obtained;  the 
parents  of  the  child  are  very  desirous  of  obtaining  a  favorable 
opinion  of  the  case,  or  do  not  recollect  all  the  suffering  the  patient 
has  endured  m  months  or  years  past.  The  surgeon  will  often  be 
informed  some  weeks  after  he  has  been  treating  the  patient,  of  some 
serious  incident  that  occurred  in  the  early  invasion  of  the  disease, 
impressing  him  with  doubts  as  to  a  favorable  result  in  treatment. 
Hence,  a  necessity  for  questioning  the  attendants  as  to  the  most 
unfavorable  circumstances  that  the  patient  could  have  labored 
under. 

False  anchylosis  is  frequently  the  result  of  disease  of  the  articu- 
lation, presenting  numerous  grades  of  severity  which,  from  previous 
disease,  have  sustained  a  very  limited  invasion  of  structure  and 
function,  or  a  great  amount  of  disorganization  by  ulceration,  adhe- 
sion, cicatrices,  and  sub-luxation  which  in  many  cases  are  amenable 
to  relief — the  contraction  being  from  a 
few  degrees  to  that  of  closely  approximat- 
ing the  heel  to  the  nates.  The  angle  may 
be  determined  by  the  gonyometer,  as  repre- 
sented in  Fig.  122. 

An  arc  of  a  circle  divided  into  180°,  hav- 
ing two  arms  of  about  eighteen  inches  in 
length ;  one  arm  attached  to  the  zenith  of 
the  arc,  the  other  being  free  and  having  an 
extension  point  that  determines  the  angle 
of  flexion  in  the  limb. 

As  before  stated,  the  history  of  the  inva- 
sion is  of  the  utmost  importance  in  deter- 
mining the  anchylosed  condition  of  the 
joint.  The  true  or  osseous  anchylosis  but 
seldom  occurs  as  a  sequence  of  scrofulous 
or   scorbutic   inflammation   in   persons   of 


Fig.  122. 


326  Orthopjedia  . 

tolerable  constitution.  In  incomplete,  or  false  anchylosis,  as 
the  latter  is  usually  termed,  and  in  which  there  is  always 
some  degree  of  mobility  that  may  be  only  perceptible  on  a 
very  careful  examination  in  a  limb  flexed  to  about  35°.  When 
ossified  union  has  ensued,  there  is  not  any  yielding  of  the 
joint  ;  and  this  may  be  most  readily  determined  by  placing  the 
patient,  if  a  case  of  anchylosis  of  the  knee,  on  a  firm  seat,  as  that 
of  a  benchj  or  narrow  seat,  elevated  a  suitable  distance  from  the 
floor,  and  firmly  strapping  the  thigh  to  the  seat,  then  ajttaching  to 
the  ankle  a  small  plummet  having  a  graduated  scale  placed  verti- 
cally to  the  plummet  line;  the  point  of  the  plummet,  in  ten  or 
fifteen  minutes,  will  determine  the  extent  of  yielding.  The  anchy- 
losis of  the  thigh  may  be  determined  by  a  similar  procedure,  fixing 
the  body  and  pelvis  firmly  to  the  bench.  Other  proceedings  than 
this  are  much  less  reliable.  The  applying  of  the  extension  splint, 
as  represented  in  Fig.  119,  is  another  tolerable  means  of  determin- 
ing the  yielding  of  the  knee  joint,  when  applied  firmly  upon  the 
flexed  limb  to  the  inducing  of  pain,  and  continued  for  six  or  eight 
minutes  ;  then,  if  pain  subsides,  and  the  bandage  has  slackened,  a 
yielding  of  the  joint  is  indicated  to  the  encouragement  of  further 
efforts.     This  is  our  most  common  practice  in  the  hospital. 

If  anchylosed  joints  yield  to  effort,  which  a  seeming  elasticity  will 
indicate,  a  favorable  prognosis  may  be  given  as  to  their  extension. 
And,  in  some  cases,  in  a  few  months;  in  others,  from  careful  per- 
severance, after  several  years  of  effort,  a  restoration,  even  of  free 
motion,  may  be  calculated  upon.  This  we  have  witnessed  in  many 
cases.  The  greatest  difficulty  is  to  keep  the  patient  satisfied  that 
they  will  eventually  reap  the  benefit  of  perseverance  in  efforts  to 
this  end.  In  cases  where  there  has  been  serious  lesion  of  all  the 
tissues  about  the  joint,  plastic  attachment  of  the  soft  tissues  ensues, 
often  binding  the  joint  most  firmly,  and  without  completing  the 
anchylosis.  This  is  the  condition  in  two-thirds  of  the  cases  that 
recover  from  the  ailment. 

There  is  a  great  tendency  in  synovitis  of  the  knee  to  subluxation 
of  the  joint;  usually  rotation  of  the  head  of  the  tibia  outwards  and 
backwards,  more  or  less,  into  the  popliteal  space;  see  fig.  123;  and 
in  some  cases,  inwards,  as  in  genu  valgum,  greatly  everting  the  front 
of  the  foot.  In  nearly  all  cases  there  is  more  or  less  flexion  of  the 
leg,  as  in  that  position  movement  outward  is  most  readily  at, 
tained.     Eotation  outward  is  effected  by  the  limited  action  of  the 


Diseases  of  the  Bones. 


327 


biceps  muscle  attached  to  the  fibula  assisted  by  the  tensor  vaginae 
femoris  which  acts  on  a  strong  band  of  the  fascia  of  the  thigh  and 
extending  downwards  to  the  leg.     Flexion  of  the  ^^    ^23 

knee  relaxes  the  ligaments,  especially  the  lateral, 
and  relieves  the  joint  which  is  sensitive  to  pressure 
of  the  articular  surfaces  when  self  effort  is  made 
to  straighten  the  limb.  From  this  we  are  impres- 
sed with  what  must  result  from  painful  extension 
force,  whilst  inflammation  exists  in  the  joint.  It 
is  only  when  this  tenderness  has  subsided  that  it 
is  safe  to  apply  extension.  This  aberration  of 
the  knee  joint  can  be  redressed  by  means  of  the 
apparatus  represented  in  fig.  124,  by  applying  the 
roller  above  the  knee,  around  the  leg  and  outer 
bar,  then  reversing  and  passing  it  below  the  knee 
and  around  the  leg  and  inner  bar,  applying  force 
in  opposite  directions:  thus  making  counter- 
pressure,  and  completing  the  whole  by  encircling 
the  limb  with  the  roller ;  a  few  turns  being  made  within  the  bars 
and  over  the  knee,  half  encircling  it.  This  meets  all  the  indica- 
tions presenting  in  the  aberration  —  flexion  and  subluxation.  Sub- 
luxation directly  backwards  results  from  synovitis 
of  the  knee  joint,  and  can  be  as  readily  reduced  as 
that  of  lateral  subluxation,  and  with  the  same 
apparatus,  half  encircling  the  leg  above  the  knee 
by  passing  the  roller  within  the  bars  and  over  the 
front  of  the  limb  above  the  knee,  then  reversing 
the  application  of  the  roller  below  the  knee,  half 
encircling  the  calf  of  the  leg. 

The  dexterous  application  of  the  roller  serves 
more  effectually  the  desired  intentions  to  be  met 
in  most  of  the  aberrations  of  the  limbs  than  any 
therapeutic  means  in  our  possession.  The  steel 
frame  serves  as  a  basis  of  support  and  resistance, 
but  their  use  is  made  available  and  complete  only 
by  the  skilful  application  of  the  roller,  by  which 
every  contortion  of  the  arm,  hand,  leg,  or  foot  can 
be  resisted  with  a  curative  tendency,  because  of 
attaining  the  most  complete  adjustment  of  the  means  to  the  pur- 
pose with  less  fixed  resistance,  than  in  the  use  of  tiie  more  complex 


Fhi.  124. 


328  Orthop^dta. 

apparatus  worked  by  screws,  they  being  unyielding  tend  to  concen- 
trated force  upon  the  salient  points  to  the  great  injury  of  the  soft 
tissues;  and  Avhich  by  their  fixed  resistance  to  motion,  impair  mus- 
cular tone  and  motion  in  joints  essential  to  the  obtaining  of  a 
normal  condition  of  the  distorted  limb.  Elasticity,  as  a  resisting 
force  to  the  redressing  of  distortion,  is  in  consonance  with  the  laws- 
of  physiology,  while  fixed  force  for  that  purpose,  is  in  opposition  to 
the  vital  forces  and  injurious  in  its  tendency,  in  direct  ratio  to  the 
extent  and  continuation  of  the  application. 

As  to  re-section  of  the  knee  joint  for  the  restoration  of  a  perpen- 
dicular condition  of  the  limb  from  flexion  and  destruction  of  the- 
articular  surfaces,  we  are  not  in  favor  of  the  practice,  because  of 
having  witnessed  many  failures ;  and  we  find  that  we  are  -not  alone- 
in  our  opposition,  for  Dr.  Holmes  Coote  of  Bartholomew's  Hospital^ 
London,  says,  in  his  work  on  Joint  Diseases,  p.  139  :  "I  am  no- 
strong  advocate  for  the  operation  of  resection  of  the  knee  joint 
under  any  circumstances,  and  disapprove  of  it  almost  uncondition- 
ally in  children,  in  whom  the  limb  becomes,  year  after  year,  weaker^ 
more  withered,  and  less  equal  to  the  opposite  member.  Dr.  Hodges 
considers  that  the  small  degree  of  success  following  the  few  cases  of 
excision  performed  for  traumatic  cases  does  not  warrant  interference 
favorable  to  its  future  adoption  as  a  substitute  for  amputation.  In 
cases  of  disease,  one  death  occurs  in  every  3  ^  operations.  There- 
fore, although  occasionally  yielding  brilliant  results,  it  is  an  opera- 
tion to  be  practiced  with  great  reserve.  Partial  operation  upon  the- 
knee,  as  in  other  ginglymoid  joints,  adds,  naturally,  to  the  number 
of  unfavorable  cases.  Inasmuch  as  the  non-removal  of  the  patella 
converts  the  excision  into  a  partial  one,  the  bone  should  never  be- 
allowed  to  remain. 

"  Re-section  among  the  young  has  its  unsatisfactory  aspects.  On 
February  14th,  1863,  one  of  my  colleagues  amputated,  at  St.  Bar- 
tholomew's Hospital,  the  left  thigh  of  a  boy,  aged  twelve,  who  had 
undergone  the  operation  of  excision  of  the  knee  joint  in  another 
hospital,  in  consequence  of  scrofulous  disease  of  the  articulation, 
about  nine  months  previously.  The  condition  of  the  boy  before 
the  second  operation  was  as  follows  :  He  was  not  much  emaciated, 
nor  had  his  face  lost  all  trace  of  the  usual  florid  color.  The  left 
lower  extremity  was  an  inch  and  a  half  shorter  than  the  opposite ; 
the  thigh  was  hot  and  swelled ;  sinuses  led  from  the  incisions  about 
the  knee  to  dead  or  denuded  bone.     There  was  some  mobilitv  at  the 


Diseases  ov  the  Bones.  329 

knee,  the  limb  was  utterly  useless,  and  the  opinion  was  general  that 
the  sooner  it  was  removed  by  amputation  the  better.  Upon  the 
usual  incisions  it  was  found  that  the  tissues  were  much  infiltrated 
and  some  considerable  sinuses  extended  upwards  among  the  muscles 
of  the  thigh.  The  hemorrhage  was  troublesome,  in  consequence 
of  the  generally  increased  vascularity  of  the  limb.  The  wound 
ultimately  cicatrized,  and  the  boy  left  the  hospital  well  and  able  to 
walk  about  on  an  artificial  limb.  The  examination  of  the  amputa- 
ted parts,  including  the  seat  of  the  resection,  was  full  of  interest. 
In  the  first  place,  very  little  of  the  bony  surface  of  the  tibia  or 
femur  had  been  cut  away  at  the  time  of  the  resection ;  their 
usual  outline  remained ;  therefore,  although  the  epiphyses  had  been 
left,  arrest  of  development  was  still  a  consequence  of  the  operation. 
Secondly,  the  greater  part  of  the  synovial  membrane  was  left  behind 
in  a  thickened,  discolored,  and  pulpy  state,  keeping  up  the  effect  of 
disease  in  full  activity.  Thirdly,  there  were  numerous  scrofulous 
abscesses  in  the  popliteal  space.  Fourthly,  there  were  two  or  more 
points  where  the  surface  of  the  tibia  and  femur  were  incomplete, 
being  partly  fibrous  and  partly  osseous;  but  the  bone  was  dark- 
colored,  soft,  sodden,  and  spongy,  and  unsuited  to  eff'ect  firm  union. 
Sixthly,  the  opposed  surfaces  were  not  in  rectilinear  apposition. 

"  Could  any  result  have  been  less  satisfactory  ?  But,  it  may  be 
said,  such  cases  are  exceptional.  I  am  not  prepared  to  acquiesce  in 
that  statement.  In  December,  1862,  another  surgeon  amputated 
the  left  lower  extremity  of  an  infant  on  whom  excision  of  the  knee 
joint  had  been  performed  a  year  before  in  another  hospital,  and  a 
third  case  occurred  in  my  own  practice,  in  which  the  parents  de- 
clined any  further  operation,  although  the  limb  was  short,  withered 
and  useless,  and  the  child  could  walk  only  with  the  aid  of  crutches. 

"We  are  told  that  excision  of  the  knee  joint  is  a  less  fatal  opera- 
tion than  that  of  amputation  of  the  thigh  ;  but  Dr.  Hodges  observes 
in  his  essay  on  the  excision  of  joints,  that :  '  Out  of  a  considerable 
number  of  cases,  one-third  died,  more  than  one-third  are  known  to 
have  failed,  and  there  is  no  direct  evidence  of  success  in  more  than 
one-third  of  the  cases,  even  accepting  the  statement  of  those  who 
furnished  the  notes.'  " 

The  experience  of  these  very  eminent  surgeons  fully  sustains  us 
in  our  objection  to  the  excision  of  the  knee  joint.  In  our  experi- 
ence but  a  very  limited  number  recover  even  under  favorable  cir- 
cumstances.    Out  of  798  oases  that  received  expectant  treatment 


330  Orthopjedia. 

in  the  Institution  for  the  Eelief  of  the  Ruptured  and  Crii)pled, 
in  eleven  years,  only  four  per  cent  failed  in  being  relieved  of  the  dis- 
ease ;  some  having  limited  motion,  and  others  perfectly  free  joints ; 
and  of  those  having  failed  to  be  relieved  under  treatment  in  the 
institution,  a  few  of  them  left  us  to  receive  other  treatment,  after 
having  been  a  long  time  under  our  care  Avithout  permanent  relief 
—  at  times  being  much  relieved,  and  again  relapsing,  and  of  these 
we  have  had  favorable  report.  The  regime  of  the  house  having 
improved  their  health  tending  to  their  cure,  even  when  subsequently 
under  a  less  favorable  condition  than  that  which  had  contributed 
largely  to  their  recuperative  tendency,  and  final  recovery.  This 
establishes  an  important  consideration  with  regard  to  hygienic 
influence  upon  this  class  of  patients.  The  physical  condition  of  the 
patient  being  improved,  tends  to  the  cure  of  the  local  disease  when 
subsequently  under  more  unfavorable  circumstances,  and  no  special 
medical  treatment. 

TKEATMENT   OF   A]SrGHTLOSIS. 

Inflammation  having  seriously  impaired  the  integrity  of  a  joint, 
three  conditions  usually  present : 

First  —  A  weakened  condition  subject  to  relief  from  supporting 
bandages. 

Second —  Fihro-celhdar  AncJiylosis,  limited  motion  in  degree  to 
that  of  the  injury  sustained  from  destructive  inflammation,  as  that 
of  thickening  and  induration  of  its  fibrous  capsule,  or  formation  of 
fibroid  bands  within  the  joint,  or  in  consequence  of  the  cartilages 
and  synovial  membrane  being  in  part  or  wholly  removed,  and  their 
place  supplied  by  a  fibroid  or  fibro-cellular  tissue,  by  which  the 
articular  ends  are  partially  united.  Muscular  contraction  often 
contributes  most  largely  to  the  limiting  of  motion  in  the  joint.  In 
some  instances  the  disuse  of  the  joint  tends  to  its  becoming  fixed  in 
position.  These  several  impairments  of  free  motion  in  the  joints 
are  all  favorable  conditions  to  restoration  from  judicious  treat- 
ment. 

TJiij-d  —  Osseous  Anchylosis  :  This  consists  of  the  indurated 
osseous  surfaces  having  coalesced  into  direct  bony  union,  and  is 
most  common  in  the  spine,  hip,  knee  and  elbow. 

The  two  first  conditions  of  the  partially  anchylosed  ioints  will  be 
considered,  and  the  means  of  relief.  When  thus  conditioned,  there 
have  been  fibro-cellular  deposits,  or  degeneration  of  the  joint ;  and 


DlSEAHKS  OF  THE  BONES.  331 

the  bones  united  by  bridges  of  osseous  matter  thrown  out  externally 
to  the  articulation  extending  across  from  side  to  side,  being  acci- 
dental formations  occurring  from  strumous  articular  inflammation 
of  considerable  duration.  When  in  this  condition  some  degree  of 
mobility,  often  very  slight  and  only  discovered  by  experienced  man- 
ipulation, may  be  detected,  tending  to  a  favorable  diagnosis. 

In  efforts  to  restore  mobility  to  partially  anchylosed  joints,  great 
care  must  be  observed  as  to  the  impression  made,  tending  to  a 
relapse  of  the  inflammation.  Carefully  applied  pressure  from  the 
roller,  as  described  in  a  previous  chapter,  upon  a  straight  splint, 
serves  as  a  valuable  means  of  restoring  normal  form  and  motion  in 
cases  of  recent  formation.  Gentle  manipulation  of  eflbrts  at  flexion 
and  extension  is  a  most  successful  treatment,  and  the  hand  the 
most  reliable  means  of  accomplishing  the  desired  object  of  restoring 
motion  to  the  joints  in  cases  of  moderate  invasion.  Some  degree  of 
motion  is  always  perceptible  in  such  cases,  and  in  many  instances 
if  left  to  the  ordinary  exercise  of  the  patient,  in  months  after  the 
inflammation  has  been  subdued  motion  is  gradually  restored.  It  is 
in  these  cases  that  the  bonesetter  obtains  flattering  encomiums  for  his 
successful  treatment,  in  having  restored  motion  to  the  stiff'ened  limb. 
In  more  obstinate  cases,  and  where  the  immobility  appears  to 
depend,  in  some  degree,  on  fibrous  bands,  they  may  be  divided  sub- 
cutaneously  and  to  the  immediate  relief  of  the  patient.  Flexion  of 
the  limb,  with  apparent  anchylosis,  is  often  the  result  of  continued 
unfavorable  position  when  in  a  painful  condition,  and  the  restora- 
tion by  means  of  extension  in  some  instances  most  tedious  and 
seemingly  impossible.  In  such  cases  the  division  of  the  tendons 
subcutaneously  assist  greatly  in  the  restoration  of  motion  to  the 
limb. 

In  the  case  of  children,  they  being  most  liable  to  invasions  of  the 
joints  from  inflammation,  when  in  a  condition  to  safely  bear  treat- 
ment tending  to  restoration  of  mobility  to  the  joints,  mechanical 
devices  for  flexing  and  extending  the  limbs  are  most  valuable  means 
•when  the  apparatus  is  so  constructed  as  to  afford  pleasurable  exer- 
cise, as  all  means  of  extension  is  attended  with  some  expense  of 
pain,  thus  serving  the  desirable  purpose  of  restoring  motion  to  the 
joint  and  not  being  objectionable  to  the  child.  This  is  of  valuable 
consideration,  as  it  tends  to  invite  a  desire  rather  than  resistance  to 
the  exercise,  as  in  that  of  a  fixed  frame  affording  monotonous  move- 
ment.    The  value  of  conjoined  mental  and  physical  exercise  to  a 


332 


I  }RTHOPuFA)IA. 


Fig.  lis. 


recuperative  tendency,  as  we  have  stated  in  a  previous  chapter  and 
here  present  as  a  practical  point  in  the  redressing  of  partially 
anchylosed  joints.  The  mechanical  device  we  use  in  restoring 
motion  to  the  hip  and  knee  joints  is  known  as  the  Locomotive  Can- 
tering Horse*     (See  fig.  125. ) 

This  locomotive  appara- 
tus consists  of  a  wooden 
horse  placed  upon  three 
wheels,  one  behind  and  two 
in  front ;  the  hind  wheel 
admitting  of  a  vibratory 
movement,  and  controlled 
by  two  wires  passing  up  to 
the  horse's  mouth  and  afc« 
tached  to  a  free  bit  of  a 
bridle.  The  rider  governs 
the  desired  direction  of  the 
horse  by  means  of  the  bridle,  as  in  that  of  riding  the  ordinary  horse. 
Two  shafts  and  the  horse's  hind  legs  are  attached  to  the  axle  of  this 
single  wheel,  and  extend  forward  to  a  crank  shaft,  and  connected 
close  to  the  axle  of  the  front  wheels,  where  there  is  an  elevation  or 
depression  in  the  progressive  movement.  The  crank  shaft,  consist- 
ing of  from  three  to  five  inches  elevation  from  the  axle,  the  horse's 
fore  legs  being  attached  to  the  elevated  portion  of  the  crank  shaft, 
admits  of  alternate  depression  and  elevation  of  the  horse's  head, 
when  power  is  applied  to  propel  the  horse  on  wheels.  The  rider 
being  mounted,  and  a  cripple,  because  of  a  stiff  knee  or  hip  (even 
partially  anchylosed),  has  his  feet  strapped  to  the  pedals  on  the 
shafts  where  they  are  kept  stationary ;  the  crank  being  elevated,  the 
rider's  weight  of  body  is  thrown  forward,  depressing  the  horse's 
head  and  crank,  and  the  movement  continued  by  the  rider  making 
effort  to  elevate  the  horse's  head.  By  these  alternate  efforts,  the 
apparatus  is  moved  and  kept  moving,  and  directed  by  the  bit. 
From  this  description  of  the  efforts  to  travel  with  the  wooden  horse, 
it  will  be  seen  that  the  legs  are  alternately  contracted  and  extended, 
to  the  overcoming  of  the  anchylosed  condition  of  the  joint.  Para- 
lytic patients  derive  much  benefit  from  this  exercise ;  and  when  one 
arm  is  paralyzed,  a  heavy  wire  must  take  the  place  of  the  bridle 


*  These  Cantering  Horses  are  manufactured  by  Stephen  W.  Smith's  Sons,  New  York 
city,  who  also  are  the  inventors  of  the  Invalid  Traveling  Chairs. 


Diseases  of  the  Bones. 


333 


Fig.  126. 


reins,  so  that  one  hand  can  direct  the  horse,  and  the  paralyzed  arm 
exercised  by  being  fastened  to  the  wire  rein. 

In  this  exercise  the  patient  requires  careful  supervision  in  limit- 
ing the  efforts  at  riding  to  the  condition  of  the  patient  ;  for,  if  per- 
mitted, he  will  indulge  to  excess,  tending  to  a  serious  relapse  of 
iniiammation  in  the  joints.  Patients  will  indulge  in  this  exercise 
even  at  the  expense  of  severe  pain,  as  we  have  witnessed  little 
patients  shedding  tears  and  yet  desire  to  ride.  Any  level  surface, 
floor  or  pavement,  can  be  made  available  for  this  exercise. 

These  horses  run  rapidly  over  any  good  road,  sidewalk,  or  park 
grounds,  propelled  by  the  weight  and  strength  of  the  rider,  flexing 
and  extending  the  legs,  arms 
and  body.  They  may  be 
made  available  for  healthful 
out-door  exercise  for  both 
adults  and  children  when 
unable  to  walk. 

Another  most  useful  means 
of  affording  exercise  in  cases 
of  paraplegia,  or  other  in- 
ability to  walk,  as  that  of 
rheumatic  seizures,  is  that 
of  the  swing.*  (See  Fig. 
126.) 

The  seat  is  suspended  by 
ropes  attached  to  the  door 
or  other  upright  frame  hav- 
ing a  cap  of  some  eight 
inches  in  breadth  from  one 
side ;  two  pendent  ropes  sus- 
pend the  seat;  on  them  is 
sheathed  handles  to  glide 
readily,  and  attached  to  two 
shorter  ropes,  secured  to 
the     opposite     side  of    the 

door  frame.  The  patient  taking  a  seat  in  the  swing  grasps  the 
handles  and  makes  efforts  at  drawing  them  down.  To  assist  in 
starting  the  swing,  a  gentle  push  may  be  given,  when  the  patient 
will  be  enabled  by  the  strength  of  his  arms  to  increase  the  move- 


*  Manufactured  by  E.  L.  Horsman,  New  York  city. 


334  Orthop^dia. 

ment,  which  is  a  pleasant  exercise,  requiring  considerable  muscular 
effort  of  both  body  and  limbs. 

Similar  devices  may  be  made  available,  thus  tending  to  pleasura- 
ble entertainment  both  physically  and  mentally,  and  contributing 
largely  as  an  auxiliary  means  to  the  relief  of  patients. 

FLOATIl^TG    CARTILAGES    IK   JOINTS. 

Slight  injuries  of  the  knee  joints  inducing  inflammation,  that 
subsides  in  many  cases  without  inviting  any  special  attention,  often 
tend,  however,  to  the  formation  of  these  adventitious  substances,  ta 
the  great  annoyance  of  the  person  thus  injured.  In  time  they 
induce  sudden  pain  with  great  uncertainty  of  walking,  and  are  met 
with  in  the  different  articulations. 

These  condensed,  spherical  substances  floating  within  the  cap- 
sules, formed  and  lined  with  the  synovial  membrane  about  joints^ 
are  not  always  found  to  be  cartilaginous  formations,  but  condensed^ 
indurated,  fibroid  tissue  simulating  a  warty  excrescence  of  the 
synovial  membrane,  usually  found  in  such  cases ;  some  of  these 
formations  being  pedunculated  and  attached,  others  floating 
about;  indicating  different  stages  of  growth,  and  that  their 
origin  was  a  warty  pathological  condition  of  the  synovial 
membrane.  They  vary  in  size,  from  that  of  a  grain  of  wheat 
to  the  dimensions  of  a  chestnut;  the  larger  being  flattened^ 
smooth,  shiny,  and  usually  of  a  yellowish  or  greyish  white 
color.  They  are  found  within  the  surroundings  of  the  knee^ 
most  commonly,  but  occur  in  the  elbow,  the  lower  jaw  and  the 
shoulder  joints,  being  in  some  cases  quite  numerous.  When 
attached  to  the  synovial  membrane  they  produce  but  little  incon- 
venience; when  loose  they  are  liable  to  be  caught  between  the 
opposite  articular  surfaces  and  produce  such  sudden  and  violent 
pain  as  to  arrest  all  motion  in  the  joint,  and  the  patient,  if  walk- 
ing at  the  time,  will  drop  as  if  shot  —  faintness  and  sickness  follow- 
ing. Eichet  thinks  it  may  be  owing  to  the  synovial  membrane 
being  pinched  between  the  foreign  body  and  one  of  the  articular 
surfaces.  Mr.  Erichsen  is  of  the  opinion  that  "  it  is  most  probably 
due  to  the  foreign  body  being  drawn  in  between  the  opposite  sur- 
faces of  the  joint  when  these  are  separated  anteriorly  in  the  act  of 
flexion  of  the  knee,  and  then,  when  the  limb  is  extended  acting  as 
a  wedge  between  these,  tending  to  keep  them  separate  and  interfer- 
ing with  the  complete  straightening  of  the  limb.     In  consequence 


Diseases  of  the  Bones.  335 

of  this  wedge-like  action  of  the  loose  cartilage  the  ligaments  are 
violently  stretched,  and  the  sickening  pain  consequent  upon  this 
act  is  experienced,  followed,  as  happens,  in  a  violent  strain  by  rapid 
synovial  effusion." 

As  regards  treatment,  this  very  skilled  surgeon  says :  "  But  it 
must  be  borne  in  mind  that  whilst  the  loose  cartilage  is  at  most  an 
inconvenience,  though  a  serious  one,  any  operation  for  its  removal 
by'which  the  joint  is  opened  becomes  a  source  of  actual  danger  to 
the  limb,  and  even  to  life.  It  is  far  less  dangerous,  in  fact,  to  leave 
the  foreign  body  than  to  perform  the  operation  necessary  for  its 
extraction."  Our  own  experience  impresses  us  with  the  same  pre- 
caution in  the  removal  of  these  substances  from  within  the  joint, 
by  operation ;  the  violent  symptoms  that  have  followed  the  pro- 
cedure endangering  the  loss  of  the  limb.  Perfect  relief  can  be 
afforded  by  wearing  the  hnee  bandage,  made  of  strong,  woven 
fabric  —  other  elasticity  being  rather  a  disadvantage  than  con- 
ducive of  any  good  purpose.  When  elasticity  is  supposed  to  be 
required,  it  should  be  of  coiled  wire  sheathed  in  chamois  leather  or 
soft  kid,  and  forming  only  one  part  of  the  bandage  — one-half  of 
the  circumference  of  the  knee.  It  is,  however,  very  clumsy,  and  by 
no  means  as  pleasant  to  wear  as  the  plain,  single  fabric.  By  this 
pressure,  in  time,  they  disappear,  and  the  wearer  of  the  knee  band- 
age has  perfect  immunity  from  the  ailment. 

Synovitic  inilammations  in  the  several  joints,  being  pathologi- 
cally alike,  require  similar  treatment :  as  they  differ  in  no  essential 
manifestation  demanding  a  special  treatment  we  leave  the  subject 
of  inflammation  audits  results  in  the  joints  of  the  limbs  —  only 
considering  the  weakness  of  the  ankle  joint  as  the  sequence  of 
strains  —  and  refer  to  a  bandage  already  referred  to,  which  affords 
quite  as  much  relief  to  the  ankle  as  that  of  the  knee  bandage 
to  the  knee  when  impaired  by  inflammation  or  these  adventi- 
tious deposits.  The  ankle  bandage  is  made  of  similar  material  as 
that  for  the  knee,  but  stiffened  under  one,  or  other,  or  both  mal- 
leoli; this  affords  most  decided  support  to  the  weak  ankle,  as  well 
as  protection  from  the  injuries  it  is  constantly  liable  to  sustain  when 
weak,  more  especially  than  when  in  a  normal  condition. 

CARIES    OF   THE   VERTEBRA. 

This  is  a  pathological  condition  of  the  vertebrae  resulting,  as  we 
believe,  from  a  dyscrasia  of  the  system  induced  most  commonly  by 


336  OrthopjEdia. 

zymotic  disease  of  virulence  and  long  continuance,  inducing  func- 
tional impairment  and  a  latent  disposition  to  synovitic  disease  tend- 
ing to  involve  the  bones.  A  bruise  or  blow  is  the  exciting  cause, 
and  if  occurring  in  the  region  of  a  joint  synovitis  tending  to  caries 
is  the  result ;  if  over  the  shaft  of  a  bone,  periostitis  and  necrosis; 
or,  if  in  the  soft  tissues  alone,  interstitial  abscess.  We  believe  this 
predisposition  may  also  exist  constitutionally  from  hereditary  influ- 
ence. Synovitis  and  caries  of  the  spine  evidently  present  in  scrof- 
ulous and  scorbutic  diathesis  which  we  believe  may  be  induced  in 
children  from  inefficient  diet,  and  bad  ventilation,  or  whatever  may 
tend  to  impair  nutrition  in  childhood.  Many  practitioners  in  med- 
icine whose  position  in  their  profession  entitles  them  to  special 
regard,  we  are  obliged  to  differ  from  in  opinion  (with  all  due  defer- 
ence) as  to  the  etiology  of  caries  of  the  vertebrae;  being  decidedly 
impressed  with  the  belief  that  there  is  a  predisposition  to  these 
lesions,  of  not  only  the  articulation  of  the  limbs  but  of  the  spine, 
and  that  the  invasion  is,  in  many  cases,  the  result  of  some  external 
violence.  Children  often  receive  severe  injuries  from  falls  or  blows, 
even  to  the  fracturing  of  their  bones,  and  recover  without  a  symp- 
tom of  synovitis  or  caries  of  the  vertebrae.  Then  why  are  they  not 
affected  with  one  or  the  other  of  these  ailments,  if  they  are  entirely 
of  traumatic  origin  ?  If  patients  were  not  predisposed  to  these  ail- 
ments they  would  be  as  readily  cured  of  contusions,  wounds,  and 
fractures,  as  healthy  children. 

Caries  of  the  vertebrae  is  most  commonly  attributed  to  an  injury 
sustained  at  some  anterior  period,  and  by  the  parents  of  the  child, 
to  some  accident,  often  to  carelessness  of  the  nurse  who  is  then  dis- 
charged, bearing  the  disgrace  of  having  so  severely  injured  the  child, 
when,  in  all  probability,  a  very  slight  injury  may  have  inadvertently 
been  the  cause,  whicli,  under  ordinary  circumstances,  would  not  have 
injured  the  child  and  thus  brought  unjust  censure  upon  the  nurse. 
The  true  history  of  the  case  invariably  reveals  the  actual  circum- 
stances that  have  preceded  the  development  of  the  disease  and 
usually  in  an  advanced  stage  when  advice  is  sought.  The  parents, 
one  or  both,  being  of  feeble  constitution,  or  the  mother,  from  vari- 
ous causes,  fails  to  afford  the  child  the  essential  nourishment  for  a 
healthy  stamina. 

DIAGNOSIS. 

Caries  of  the  vertebrae  is  one  of  the  most  insidious  ailments  of 
childhood.     At   first,    slow   of  progress,   and   attended   with   very 


Diseases  of  the  Bowes. 


337 


Mg.  127. 


decided  indications  unobserved  by  most  of  parents,  or  those  having 
charge  of  the  afflicted  child,  as  before  stated,  treatment  is  sought 
mainly  in  the  advanced  stage  —  a  slight  projection  beyond  the  lim- 
its of  the  other  spinous  processes.  This  is,  in  some  cases,  months 
after  the  invasion  or  incipient  stage  of  the  ailment  has  passed.  In- 
flammation has  preceded  absorption  of  the  interstitial  substance 
tending  to  the  angular  projection  from  an  approximation  of  the 
bones  of  the  vertebrae. 

From  close  observing  intelligent  parents,  we  learn  the  first  indi- 
cation of  a  tendency  to  caries  of  the  spine  —  an  apparent  lassitude, 
and  disposition  of  the  child  to  recline  the  breast  upon  the  seat  of  a 
chair  or  other  convenience  for  resting.  If  in  active  play,  after  a 
time  the  child  will  assume  a  semi-reclining  position  —  the  shoulders 
advanced,  with  a  slight  flexion  of  the  legs,  and  run  to  a  chair  to 
assume  the  position  described,  and  frequently  complain  of  pains  in 
the  stomach  or  bowels,  while,  to  an  ordinary  observer,  the  child  is 
in  apparent  good  health.  After  reclining  for  some  time  an  effort  will 
be  made,  slowly  (for  a  child  in  good  health), 
by  the  arms  to  gently  raise  the  body,  and 
steps  are  at  first  softly  taken,  when  the  play 
is  again  resumed  with  the  usual  vivacity. 
This  incipient  stage  may  exist  without  in- 
crease, apparently,  for  several  months  in 
some  cases;  in  others,  but  a  few  weeks.  On 
examination  of  the  spinal  column  it  is  but 
seldom  that  a  tender  point  is  found.  In 
most  cases  a  slight,  limited  inrntrvation 
in  some  portion  of  the  spinal  column  will  be 
observed,  and  that  may  arise  from  a  swelling 
of  the  intervertebral  substance  from  inflam- 
mation and  congestion.  This  indication  will 
be  observed  by  close  examination  in  a  majority  of  the  cases  of  in- 
cipient caries  of  the  spine,  and  an  apparent  disposition  to  steady  the 
spine  by  limiting  its  normal  elasticity  in  conformity  to  the  move- 
ments in  walking,  which  stiff'ness  increases  as  the  disease  advances. 
Dyspnoea,  or  interrupted  breathing,  is  an  early  symptom,  increasing 
as  the  ailment  progresses  and  becoming  eventually,  if  not  a  serious 
concomitant,  a  great  annoyance. 


338 


Orthop^dia. 


KYPHOSIS,    OE   POSTERIOE   CURVATURE   OF   THE   SPIIfE. 

After  these  first  indications  have  passed,  it  is  then  that  the  sur- 
geon is  consulted,  because  of  the  discovery  of  a  small  projection  of 
the  spine,  -after  months  have  passed,  which  is  the  most  decided 
symptom  of  the  advanced  ailment.  The  family  physician  has 
already  been  consulted  and  failed  to  discover  the  true  condition  of 
the  patient,  because  of  his  not  having  had  a  case  within  his  sphere 
of  practice  for  several  years,  although  his  practice  may  be  extensive. 
This  truly  unfortunate  circumstance  is  much  to  be  deplored,  as  it 
in  many  cases  precludes  the  possibility  of  arresting  the  deformity. 
The  cancellated  portion  of  the  vertebrae  being  in  a  state  of  dissolu- 
tion and  absorption,  clinical  teaching  is  not  readily  attained,  nor 
are  persons  possessed  of  information  in  special  regard  to  the  ail- 
ment, the  treatment  of  which  has  mainly  been  left  to  adventurous 
practice,  regardless  of  the  actual  pathological  condition  of  the 
patient ;  and,  when  in  advanced  stages  an  exclusive  reliance  upon 
some  patented  spinal  supporter  is  all  that  is  tendered  to  the  unfortu- 
nate patient,  when  the  most  skilfully  constructed  spinal  supporter  is 
only  auxiliary  to  skil- 
ful treatment.  When 
the  caries  is  in  the 
sixth  and  the  sev- 
enth dorsal  vertebrae, 
and  only  a  single, 
limited  projection, 
the  form  of  the  per- 
son is  but  slightly 
impaired,  as  in  Fig. 
128.  Or,  when  aflect- 
ing  the  lumbar  ver- 
tebrae, as  seen  in  Fig. 
129. 

But  when  the  caries 
advances,  and   more 
especially  in  the  lum- 
bar vertebrae,  the  body  is  thrown  forwards,  and  a  disposition  made 
to  support  it  by  grasping  the  legs  above  the  knees  to  support  the  body 
when  walking. 

Paralysis  but  seldom  ensues  when  the  caries  affects  these  portions 


Diseases  of  the  Bones. 


339 


of  the  spine,  altliough  the  projection  is  very  large  and  limiting  the 
stature,  as  seen  in  the  last  figure,  tending  to  an  increase  of  anterio- 
posterior deflection.  Even  at  this  stage  the  patient  is  amenable  to 
relief,  both  as  to  form  and  condition  of  health ;  not,  however,  to 
the  restoration  of  the  normal  form  of  the  spinal  column.  Any 
effort  at  reducing  the  angular  projection  is  attended  with  the  most 
serious  consequences,  even  to  the  compromising  the  life  of  the 
patient. 

The  progress  of  the  disease  or  pathological  condition  from  incipi- 
ency  to  the  absorption  of  the  bodies  of  the  vertebrae,  demands 
our  especial  attention  to  prevent  the  sad  deformity  that  ensues  from 
inefficient  treatment. 

Inflammation  having  invaded  the  intervertebral  cartilages,  soon 
involves  the  cancellated  structure  of  the  bone,  and  as  ulceration 
proceeds  the  angle  increases,  and  becomes  more  or  less  acute,  accord- 
ing to  the  number  of  vertebrae  affected  and  the  loss  of  substance. 
This  impairs  the  physical  integrity  of  the  spinal  column,  rendering 
it  no  longer  a  center  for  sustaining  the  weight  of  the  head  and 
shoulders ;  and  if  not  supported  with  a  properly  constructed  brace 
the  flexion  and  attrition  become  a  mechanical  irritant.  As  the 
disease  progresses  pain  increases  upon  motion,  but  more  especially 
from  that  of  a  sudden  step  or  jolting  in  a  traveling  conveyance. 
The  general  health  suffers  from  constant  irritation,  the  appetite 
fails,  the  bowels  become  irregular,  the  secretions  morbidly  condi- 
tioned, tending  to  hectic  fever  and  abscess. 
The  anterior  surfaces  of  the  vertebrae  being 
the  primary  seat  of  the  invasion,  extending 
in  some  cases  to  one  side  more  than  to  the 
other,  the  body  inclines  greatly  to  the  side, 
yielding  from  the  loss  of  substance,  as  seen 
in  the  last  engraving.     Fig.  130. 

At  this  stage  of  the  ailment,  in  many 
cases,  abscess  is  formed,  and  indicated  by 
increased  disturbance  in  the  general  health 
and  by  an  enlargement  on  either  side  of  the 
projection  or  in  the  lower  parts  of  the  body. 

On  examination  of  the  diseased  vertebrae 
the  indications  of  pre-existing  inflammation 
are  readily  discovered  by  the  textural  disin- 
tegration,   ulceration,    abscess    and    caries. 


Ficj.  130. 


340  OrthopJedia  . 

The  abscess  is  imbedded  in  the  substance  of  the  bone,  or  found 
near  the  surface.  They  vary  both  in  form  and  size;  some  con- 
tain pus,  others  pus  and  blood,  and  still  others  contain  pus  sur- 
rounding the  diseased  bone.  The  matter  in  many  cases  becomes 
inspissated  by  absorption  of  its  watery  constituents,  when  it 
acquires  a  yeltew  color  and  thicker  consistency.* 

In  cases  of  progressive  disease  the  disintegration  of  bone  proceeds 
until  great  loss  of  subatance  ensues,  the  vertebral  column  yields, 
and  the  spine  projects  to  an  extraordinary  degree ;  the  patients 
recovering  after  the  invasion  of  from  two  to  six  vertebrae,  and 
retaining  their  power  of  locomotion.  It  is  usually  in  these  sad 
cases  that  internal  abscesses  form  and  descend,  often  of  very  great 
.size,  containing  a  large  quantity  of  watery  matter,  passing  down 
the  course  of  the  psoas  muscle  and  presenting  in  the  thigh,  consti- 
tuting "  psoas  abscess ; "  or,  forming  behind  the  tendinous  origin 
of  the  transversalis  muscle  and  presenting  in  the  loins,  constitut- 
ing a  lumbar  abscess,  and,  in  some  cases,  in  the  region  of  the  dis- 
eased vertebrae.  They  present  internally  in  some  cases,  and  enter 
the  bronchi  or  coloii,  by  no  means  observing  any  regularity  in  their 
tendency.     This  sad  occurrence  is  but  rarely  met  with. 

In  adults  the  symptoms  vary  considerably  from  those  of  child- 
hood. If  the  disease  is  located  in  the  cervical  vertebrae,  as  the 
bodies  are  comparatively  thin,  caries  rapidly  penetrates  to  the  spinal 
canal,  involving  the  cord,  endangering  thereby  the  life  of  the 
patient.  Where  the  dorsal  or  lumbar  vertebrae  become  diseased  the 
lesion  is  not  so  serious  in  regard  to  life,  but  if  not  arrested  in  the 
early  stage  of  the  ailment  great  deformity  ensues,  to  the  compres- 
sion of  the  thoracic  and  abdominal  viscera,  inducing  difficult  breath- 
ing and  severe  attacks  of  asthma.  We  have,  in  some  cases,  caries 
without  angular  curvature  impairing  the  flexibility  and  mobility  of 
the  spine,  and  thus  compelling  the  patient  to  retain  the  body  in  a 
fixed  position  when  walking,  and  when  lying  upon  the  back  unable 
to  raise  from  the  position  without  help.  The  lower  limbs  now 
become  weak,  the  patient  walks  unsteadily,  and  the  health  partly 
fails  because  of  mental  depression  on  contemplatmg  such  deplorable 
prospect  from  the  progressing  inability  to  walk.  The  weakness  is 
especially  marked  in  going  up  stairs,  as  they  labor  under  an  inabil- 
ity to  stand  on  one  leg  and  raise  the  other.  Spasm  of  the  mus- 
cles of  the  lower  extremities,  with  a  tendency  to  relaxation  of  the 

*  Holmes  Coote  on  Joint  Diseases,  p.  159. 


Diseases  uf  the  Bones.  341 

sphincter  ani  and  retention  of  urine  are  accompanying  symptoms. 
In  some  cases  abscess  forms  before  deformity  is  apparent.  Mr, 
Stanley  remarks  that  pain  and  irritation  of  tlie  spinal  cord  are 
usually  lessened  for  a  time  after  abscess  has  formed.  Mr.  Erich  sen 
remarks,  in  his  work  on  the  Science  and  Art  of  Surgery,  p.  788 : 
"  It  must  not,  however,  be  supposed  that  abscess  necessarily  forms 
in  all  cases ;  indeed,  the  formation  of  matter  will,  I  believe,  chiefly 
depend  upon  whether  the  disease  of  the  vertebrae  be  tuberculous  or 
not.  Simple  congestive  or  inflammatory  caries  of  the  spine  may 
take  place  to  a  very  considerable  extent,  and  yet  no  suppuration 
occur ;  the  bodies  of  the  vertebrae  undergoing  erosion  and  absorp- 
tion, and  coalescing  so  as  to  become  fused  together  into  one  soft 
and  friable  mass  of  bone  across  which  bridges  of  osseous  tissue  are 
sometimes  thrown  out  so  as  to  strengthen  the  otherwise  weakened 
spine.  In  these  cases,  masses  of  porcelaneous  deposits  will  not 
unfrequently  be  found  intermingled  with  and  adhered  to  the  cari- 
ous bone.  Indeed,  this  anchylosis  and  fusion  of  the  bodies  of  tlie 
diseased  vertebrae  may  be  looked  upon  as  the  natural  mode  of  cure 
of  angular  curvature  of  the  spine ;  the  only  way  in  which  it  can 
take  place  when  once  the  disease  has  advanced  to  any  considerable 
extent."  This  is  the  most  probable  rationale  of  the  process  of  cure 
in  cases  of  caries  of  the  spine. ' 

Diagnosis  of  abscess  arising  from  caries  of  the  spine  is  in  some 
cases  very  diflScult  to  determine ;  the  only  guidance  and  tolerable 
certainty  being  in  the  history  of  the  case,  as  before  stated;  its  course 
to  external  development  is  not  limited,  often  presenting  in  localities 
subject  to  abscess  ;  as  in  the  groin,  where  we  have  lymphatic  collec- 
tions in  the  subcutaneous  and  cellular  tissues;  from  the  cellular 
tissues  about  the  kidneys,  pericoecal  abscess ;  abscess  in  the  iliac 
fascia,  from  hip  disease ;  glandular  abscess,  from  empyema  perforat- 
ing the  pleura  and  passing  down  behind  the  diaphragm.  In  all 
these  cases  there  is  an  absence  of  pain  in  the  dorsal  region  and  no 
spinal  projection,  which  is  a  most  common  attendant  upon  psoas 
abscess.  If  the  abscess  is  perinephritic,  there  would  be  symptoms 
of  renal  disease.  In  other  rare  cases  the  attendant  symptoms  usually 
determine  the  ailment  with  tolerable  certainty. 

Prognosis  in  spinal  caries  is  much  more  favorable  in  children 
than  in  adults.  Children,  even  after  complete  paraplegia  and  anass- 
thesia,  will  recover  from  both  in  ratio  to  the  reduction  of  inflamma- 
tion.    The  occurrence  of  abscess  renders  the  prognosis  less  favorable 


342  Orthopjedia. 

on  account  of  its  influence  upon  the  vital  energy  of  the  system.  It 
is  remarkable  that  psoas  abscess,  in  some  cases,  is  attended  with  less 
implication  of  the  spinal  cord  than  in  those  where  no  suppuration 
presents ;  but  where  these  are  indicative  of  active  inflammation  and 
softening  of  the  spinal  marrow,  marked  by  prolonged  nervous 
symptoms  and  total  paralysis  of  the  sphincter  ani,  the  prognosis 
becomes  deeidely  unfavorable. 

Children  recover  after  several  years  progress  of  the  disease,  having 
accessions  of  various  intercurrent  disorders  ;  irritable  and  tumid 
bowels,  hectic  fever,  vesical  irritation,  discharging  abscess,  and  bed- 
soi-es.  If  nutrition  can  be  sustained  after  the  acute  symptoms  have 
passed,  there  is  a  tolerable  prospect  for  recovery  ;  that  is,  to  an 
arrest  of  inflammation,  consequent  pain,  and  dissolution  of  tissues, 
minus  the  parts  and  j^rocesses  that  have  been  wasted  in  morbid 
secretions.  The  nervous  tissues  maintain  their  integrity  to  a 
greater  extent  than  any  other  tissue. 

CAKIES    OF   THE    CEEVICAL   VERTEBRA. 

The  tendency  to  caries  of  the  cervical  vertebrse  in  children  claims 
special  consideration,  as  in  its  progress  peculiar  impairment  to  the 
physical  condition  of  the  system  presents;  as  that  of  most  painful 
neuralgia,  in  some  cases  followed  by  paraplegia  and  partial  para- 
lysis of  the  pelvic  viscera,  which  but  seldom  supervenes  in  caries  of 
the  lower  portion  of  the  spinal  column. 

When  the  disease  presents  in  the  first  and  second  articulations  of 
the  cervical  vertebrse,  it  constitutes  one  of  the  most  serious  forms 
of  vertebral  caries.  The  movement  of  the  head  is  limited  from 
pain  and  swelling  attended  with  the  formation  of  abscess  that  tends, 
in  some  cases,  externally,  and  in  others  into  the  cellular  tissue 
behind  the  pharynx  and  extending  along  its  posterior  wall  against 
the  nasal  aperture,  even  to  the  extruding  of  the  tongue,  occasioning 
much  suffering  from  a  difficulty  of  breathing.  In  these  cases  the 
sterno-raastoid  muscles  are  made  tense  and  prominent,  and  the  neck 
perfectly  rigid,  with  a  disposition  to  support  the  head  with  both 
hands  under  the  chin.  This,  in  some  cases,  has  proved  fatal  from 
luxation  of  the  vertebrae  forwards,  causing  compression  of  the  cord, 
in  others  from  hectic  exhaustion.  The  patient  having  recovered 
from  this  fearful  condition  is  usually  left  with  a  peculiar  position 
of  the  head;  the  occiput  elevated,  and  chin  depressed;  inability  to 


Diseases  of  the  Bones. 


343 


.  131. 


turn  the  head,  and  a  round  prominence  upon  tlie  upper  posterior 
portion  of  the  neck. 

The  next,  and  much  more  common  seat  of  the  disease  in  the 
cervical  vertebrae,  is  inflammation  involving  the  last  cervical  and 
first  dorsal,  producing  a  very  peculiar  series  of  painful,  consecutive 
implications.  The  first  indication  is  that  of  a  set  position  of  the 
head  and  neck,  attended  in  some  cases  with  most  excruciating  pain 
on  motion,  and,  frequently,  when  in  a  state  of  rest.  The  sensa- 
tions extend  over  the  cervical  fascia.  This  severe  neuralgic  seizure 
is  apparently  the  only  ailment  of  the  child,  in  some  cases  for  several 
months,  when  progressive  paraplegia  will  be  observed,  with  inability 
to  control  the  sphincter  ani ;  the  paralysis  supervening  in  nearly 
every  case  where  the  disease  is  not  arrested  in  its  incipiency.  The 
paralysis,  however,  in  these  cases,  being  strictly  from  local  cause, 
is  recovered  from  in  time,  as  the  active  stage  of  the  disease  subsides. 
It  is  remarkable  that  motor  paralysis  should  be  a  concomitant' of 
the  inflammation  of  the  last  cervical  and  first  dorsal  vertebrae;  and 
even  as  caries  increases  in  development,  re- 
covery from  the  paralysis  is  progressing,  as 
we  have  witnessed  in  many  cases.  From 
this  we  must  not  infer  that  it  is  caused  by 
compression  from  angular  curvature,  for  the 
paralysis  precedes  the  curvature ;  and,  yet, 
the  patient  is  more  readily  relieved  from 
spinal  support  by  suspending  the  head,  than 
by  any  other  treatment.  Paralysis  seldom 
results  from  incipient  invasion  of  the  dorsal 
or  lumbar  vertebrae,  unless  it  is  of  traumatic 
origin  and  actual  fracture  of  the  vertebras. 

The  incipient  or  active  inflammatory  stage 
having  subsided,  and  absorption  of  the  inter- 
vertebral substance  and  bodies  of  the  bone 
advanced,  a  small  knuckle-like  projection  will 
be  observed,  and  the  patients  restored  to  the  use  of  their  limbs. 
See  Fig.  131. 

This  condition  of  the  patient  is,  in  many  instances,  maintained, 
the  patient  possessing  a  tolerable  stamina  of  constitution,  although 
a  paralysis  may  have  supervened  and  recovery  eventuated  as  the 
inflammatory  stage  subsided ;  but  most  commonly  caries  of  the 
vertebral  bones  progresses  to  deformity,  as  seen  in  Fig.  132,  and 


344 


Obthop^dia. 


Fig.  132. 


the  patient  eventually  enjoys  a  toler- 
able condition  of  health.  This  favorable 
result  is  not  always  obtained,  and  we  have 
abscess  in  those  cases  where  caries  has 
continued  to  the  destruction  of  the  bodies 
of  the  diseased  vertebrae,  in  some  cases, 
months  after  it  is  supposed  the  disease  has 
been  arrested.  As  the  ulceration  affects 
the  anterior  surfaces  of  the  bodies  of  the 
vertebrse,  it  is  in  this  situation  the  abscess  is 
formed.  Matter,  having  formed  in  this  loca- 
tion has  passed  the  entire  length  of  the  body 
and  presented  in  the  iliac  region,  and  in 
front  of  the  thigh,  and,  in  some  cases,  has 
perforated  the  rectum,  and  the  patient  re- 
covered after  months  of  suffering. 


TREATMENT    OF   CARIES    OF   THE   SPINE. 

In  the  treatment  of  incipient  or  advanced  caries  of  the  spine 
favorable  hygiene  is  required,  as  success  depends  mainly  upon  the 
enforcement  of  a  suitable  regime  and  proper  sanitary  relations 
thereto,  and  which  is  imperative  to  the  making  of  nutrition  avail- 
able to  the  recuperative  powers  essential  to  an  arrest  of  the  disease* 
This  favorable  condition  can  most  readily  be  obtained  in  a  well 
designed  hospital.  Patients  at  home  meet  with  many  interruptions 
to  progress  in  cure  from  unfortunate  indulgences,  to  their  serious 
injury.  This  is  the  experience  of  every  surgeon  in  attending  to 
private  practice.  It  is  possible  to  obtain  a  prescribed  diet,  and 
medicines  administered  at  stated  periods,  but  it  is  impossible  to 
have  an  observation  of  all  the  circumstantial  incidents  to  the  sur- 
rounding and  varied  condition  of  the  patient,  that  would  govern 
the  surgeon  in  determining  upon  a  suitable  diet  and  medication. 
Proper  ventilation  is  not  readily  obtained  in  a  private  chamber ; 
monotonous  confinement  tends  to  torpidity  of  the  vital  energies 
and  to  the  increase  of  local  excitement  from  concentration  ;  and 
the  want  of  diffusion  from  pleasurable  mental  and  muscular  exercise, 
which  excites  assimilation  and  a  demand  for  nutrition.  Hence,  a 
hospital  especially  designed  for  this  class  of  chronic  ailments  con- 
tributes most  largely  to  their  cure,  from  the  advantages  accruing 
from  persistent  treatment. 


Diseases  of  the  Bones.  345 

Children  laboring  under  chronic  disease  of  the  Joints  or  osseous 
tissue,  confining  them  for  a  great  length  of  time  to  the  bed  or  room, 
become  greatly  depressed,  even  to  despondency,  and  form  a  dislike 
to  any  interruption  from  contemplating  their  increasing  deplorable 
condition ;  the  mind  becoming  morbidly  sensitive  to  any  interfer- 
ence, by  treatment,  that  would  tend  to  their  benefit,  while  their  only 
desire  is  to  be  undisturbed.  Then  parents  and  fi'iends,  expressing 
their  sympathy,  contribute  greatly  to  increase  this  tendency.  And, 
in  many  instances,  these  promiscuous  influences  are  unavoidable  at 
their  homes,  even  in  the  most  opulent  families.  Social  enjoyment 
is  only  attainable  among  a  number  of  joyous  children,  where  a 
selection  of  suitable  companions  can  be  found,  as  may  be  daily 
observed  in  the  Hospital  for  the  Relief  of  tbo  Ruj)tured  and  Crip- 
pled, where  children  from  comfortable  homes  and  those  from  no 
homes  are  associated.  The  little  patient,  on  entering,  is  quite  home- 
sick for  a  day  or  two  in  some  instances,  but  by  no  means  are  all  so 
afiected,  as  pleasurable  entertainment  is  made  one  of  the  essentials 
to  the  regime  of  the  house,  and  in  which  the  child  becomes  inter- 
ested. Some  children  take  part  in  these  amusements  at  once,  while 
others  remain  in  their  acquired  quiescent  condition  for  days,  so 
depressing  has  been  the  surroundings  at  home,  and  excessive  the 
drains  from  large  abscesses.  The  child  having  failed  to  take  a 
nourishing  diet,  because  of  frequent  persuasion  at  irregular  periods, 
is  supposed  by  the  parent  to  be  in  a  starving  condition  from  its 
refusal  to  eat  a  reasonable  portion  of  nourishing  food;  forgetting 
that  the  child  had  been  hourly  tempted  to  eat  something  pleasing 
to  the  taste,  however  unsuitable  as  a  diet  in  its  enfeebled  condition. 
A  child  in  this  condition  having  entered  the  hospital  is  offered  a 
suitable  diet  at  stated  periods  ;  if  it  is  refused,  no  attention  is  made 
apparent  until  the  next  period,  and  this  course  is  continued.  From 
time  to  time  the  child  takes  a  small  portion  of  the  food,  and  within 
a  week  will,  in  most  instances,  astonish  its  parents  by  the  excellent 
appetite  it  will  display,  and  the  quantity  it  will  eat  at  a  meal.  This 
is  entirely  contingent  upon  taking  food  at  stated  periods,  and  upon 
the  excited  energy  induced  by  freely  associating  and  joining  in 
with  the  other  children  in  their  amusements ;  even  when  confined 
to  bed,  amusements  are  offered  the  child  and  it  is  induced  to  Join 
in  them.  Music  contributes  usually  most  largely  to  the  pleasure 
of  the  child,  and  if  it  can  be  induced  to  join  in  singing  it  is  one  of 
the  most  salutary  exercises  that  can  be  offered  the  feeble  little 


346  OrthopjEdia. 

pa'uent,  even  though  not  able  to  sing  above  a  whisper.  Whether  it 
is  the  increased  quantity  of  oxygen  inhaled,  or  the  pleasurable 
excitement  to  the  nervous  system,  or  both,  we  are  not  prepared  to 
say,  but  state  the  result  as  contributing  largely  to  an  increase  of 
appetite  and  a  solace  to  their  suflFerings;  for  while  singing  they 
cease  complaining  for  the  time,  and  for  some  time  after. 

Children  disposed  to  move  about  without  being  much  inconveni- 
enced from  pain,  should  not  be  confined  to  bed,  as  it  tends  greatly 
to  torpidity  of  the  physical  power  and  depression  of  the  mental 
faculties.  The  physical  powers  are  accelerated  by  pleasurable  reflec- 
tions which  tend  to  a  demand  for  nutrition  and  a  consequent 
increase  of  vitality  —  the  only  power  of  resistance  to  disorganiza- 
tion, or,  in  other  words,  disease,  under  whatever  form  it  may  present. 
Temperature  and  ventilation  claim  special  consideration,  and  can 
only  be  made  available  in  apartments  designed  for  the  purpose,  and 
having  capacity  and  construction  to  supply  each  individual  with 
not  less  than  nine  hundred  cubic  feet  of  air,  and  a  change  every 
ten  seconds  ;  the  air  passing  off  through  registers  in  the  floor, 
beneath  which  the  entire  space  should  constitute  an  air  chamber 
connected  with  a  heated  conduit  of  some  eighty  feet  in  height,  kept 
at  a  temperature  of  120°,  thus  obviating  the  pernicious  influence  of 
inhaling  the  diff'used  gases  arising  from  purulent  foetid  matter 
emanating  from  discharging  abscesses  and  foul  breath.  It  is  pure 
air  that  should  be  supplied  the  patient,  protecting  him  from  mias- 
ma or  py^emic  influence;  the  most  common  cause  of  failure  when 
otherwise  skilfully  treated.  Proper  ventilation  is  of  primary  import- 
ance in  the  preliminaries  of  preparatory  arrangements  for  treatment. 
In  an  ordinary  dwelling,  there  being  a  tire-place,  a  tolerably  pure 
condition  of  atmosphere  can  be  obtained  by  having  a  fire  in  the  fire 
place,  or  a  jet  of  gas  burning  therein,  and  this  should  be  made 
available  at  all  seasons  of  the  year.  When  damp  easterly  winds 
prevail  in  midsummer,  or  close  rainy  weather,  the  room  where 
there  is  a  patient  laboring  under  any  of  these  chronic  ailments, 
there  should  be,  invariably,  heat  in  the  open  fire-place.  .  This 
would  give  a  more  rapid  change  of  air,  essential  to  the  escape  of 
any  morbid  exhalations  emanating  from  open  disease  or  body.  Fre- 
quent sponging  and  cleansing  the  body  and  limbs,  keeping  the  skin 
in  a  moist,  pliant  condition,  is  a  most  salutary  means  of  improving 
the  condition  of  the  patient.  To  free  the  emuuctories,  and  promote 
excreta  from  the  cuticular  surfaces  is  of  nearly  as  much  importance 


Diseases  of  the  Bones.  347 

as  that  of  the  regulai-  3vacuati.ons  of  the  internal  organs,  and,  when 
carefully  incited  to  a  normal  condition,  tend  largely  to  the  cure  of 
the  local  ailment.  As  it  is  invariably  to  be  observed  in  these  chronic 
conditions,  the  skin  is  torpid  in  its  secretory  functions,  there  being 
a  deficiency  of  vital  energy;  a  shriveled,  dry,  inelastic  condition  as 
in  the  case  of  an  excessive  internal  irritation.  This  is  in  the  incipi- 
ency  of  the  ailments,  and  for  a  time  during  their  susceptibility  of 
cure.  When  the  system  becomes  prostrate,  as  in  chronic  diarrhcea, 
or  draining  abscess,  the  emunctories  of  the  skin  become  patulous 
from  an  extreme  loss  of  vitality,  and  the  sweating  stage  ensues. 

The  diet  of  the  patient  laboring  under  these  chronic  ailments  is 
of  the  utmost  importance,  and  is  dependent  upon  the  sanitary  rela- 
tions having  prepared  the  assimilative  functions  for  the  reception  of 
nutriment.  When  this  has  been  accomplished,  suitable  nutrients 
are  not  only  to  be  selected  but  carefully  prescribed  in  suitable  quan- 
tity, quality,  and  at  stated  periods.  This  requires  close  observation 
of  the  patient's  condition  and  habits.  An  excess  in  quantity  of 
solids  or  fluids  in  diet,  is  as  inimical  to  health  as  a  pernicious  selec- 
tion, and  if  taken  at  irregular  periods  disposes  the  digestive  function 
to  a  morbid  tendency.  If  the  food  is  not  properly  digested,  the 
quality  of  the  blood  is  impaired,  the  general  function  of  nutrition 
fails  to  sustain  an  extraordinary  demand  —  that  of  the  normal 
supply  and  the  drain  of  the  abscess  or  ulcer.  The  disease  thus 
obtains  an  ascendency  to  the  increasing  depression  of  the  whole 
organization,  arresting  in  degree  the  recuperative  tendency.  By 
moderately  exciting  the  digestive  forces  we  tend  to  restore  the  due 
qualities  to  the  blood,  and  the  energy  of  nutrition  —  the  stomach 
recovers  its  powers  when  properly  nourished,  and  a  normal  condi- 
tion is  restored — tending  to  recuperative  energy  and  ability  of  vital 
force  to  relieve  the  system,  even  of  local  irritation  and  destruction. 
The  restoration  of  normal  power  in  the  stomach  is  of  primary  im- 
portance, inviting  very  special  consideration.  An  excess  of  func- 
tional effort  exerted  upon  the  most  valued  nutrients  will  prove 
inimical,  and  tend  to  the  destruction  of  the  patient.  Careful 
observation  and  experience  in  selection  and  quantity,  determining 
the  power  of  the  stomach  to  digest  in  every  case  that  presents  for 
treatment,  is  that  which  will  contribute  most  largely  to  successful 
practice. 


348 


Orthop^dia. 


"MEOHAKICAL   APPLIANCES. 

Holmes  Coote  on  Joint  Diseases,  published  1867,  p.  164,  says ' 
"  A  carious  spine  is  unfit  to  support  the  superincumbent  weight ;  it 
is  not  suited  to  the  moyements  necessary  in  progression ;  no  appar- 
atus, however  skilfully  made,  is  fitted  for  a  case  of  actual  disease, 
and  yet  the  patient's  recovery  depends  on  the  function  of  nutrition 
being  well  carried  on,  a  process  to  which  exercise  is  most  necessary."' 
This  eminent  writer  believes  exercise  to  be  imperative  to  the 
recovery  from  caries  of  the  spine,  but  objects  to  spinal  supports. 
This  last  is  because  of  their  imperfect  construction,  and  impinging 
upon  the  diseased  spine  they  become  a  source  of  irritation.  A  skil- 
fully devised  brace  or  supporter  is  of  inestimable  benefit,  because 
of  its  enabling  the  patient  to  take  exercise  with  impunity,  and 
thereby  obtain  a  very  necessary  part  of  the  treatment.  The  spine 
supporter  we  have  applied  invariably  affords  great  relief  to  those 
laboring  under  caries  of  the  spine  in  all  stages.  If  applied  in  the 
incipient  stage  it  arrests  aberration  of  the  spinal  column  and 
sternum,  that  is,  if  the  patient's  stamina  is  susceptible  of  improve- 
ment from  a  strictly  enjoined  regime  and  alterative  remedies.  The 
spine  supporter  we  now  use  we  devised  over  twenty  years  since. 

It  will  be  observed  that  it  is  a  light  steel 
frame  encircling  two-thirds  of  the  body. 
A  back  view  is  presented.  The  lower  bars 
rest  upon  the  crest  of  the  ilium,  and  the 
two  longitudinal  bars  extend  below,  thus 
giving  a  lengthened  support,  and  obtain- 
ing greater  firmness,  so  that  if  the  caries 
should  be  in  the  lower  lumbar  regions 
no  injury  could  be  sustained  from  pressure. 
Shoulder  straps,  well-padded,  pass  from 
the  front  over  the  shoulders  and  button  on 
the  cross-bar,  passing  over  the  scapulae  and 
under  the  axillae.  Strong  woven  fabric 
incloses  the  front  by  lacing. 

It  will  be  observed  that  this  brace  gives 
lateral  support  and  not  extension;  giving  a  fixed,  non-elastic  sup- 
port, thus  arresting  motion,  and  consequently  attrition  in  the  artic- 
ulations of  the  diseased  vertebrse  —  being  the  first  intention  to  be 
met  with  a   therapeutic  agent  (in  our  opinion),  and  confirmed  by 


Fi\    133. 


Diseases  of  the  Bones. 


349 


Fig.  134. 


the  benefit  they  have  afforded  many  hundreds  of  persons  afflicted, 
from  two  to  thirty  years  of  age :  enabling  them  to  take  exercise 
with  impunity.  Certain  modifications  are 
required  for  the  several  points  of  the  spinal 
column  that  may  be  diseased.  The  two 
vertical  bars  to  the  spinal  column  have  to 
be  carried  above  the  scapular  cross-bar 
when  the  caries  is  in  the  upper  dorsal 
region ;  and  when  in  the  lower  dorsal  and 
lumbar  regions  the  tendency  of  the  body 
to  incline  to  one  side  is  corrected  by  ex- 
tending a  small  bar  of  steel  from  the  lower 
cross  band,  having  a  pad  attached  and  in- 
tended to  press  upon  the  hip  of  the  side 
inclined  to,  and  thus  the  body  is  sustained 
in  the  erect  attitude.  See  Fig.  134,  back 
view. 

This  same  form  of  brace  is  made  available  to  support  the  head ; 
an  essential  addition  in  cases  of  caries  of  the  cervical  vertebrae,  and 
more  especially  in  cases  of  disease  located  in  the  last  cervical  and 
first  dorsal  vertebras;  in  all  cases  relieving  the  paraplegia  that 
subsequently  ensues  from  caries  in  this  region,  as  well  as  the 
•distressing  neuralgic  suffering  attendant  upon  the  same.  This 
form  of  apparatus  has,  in  many  cases,  re- 
lieved torticollis  by  having  a  very  firm 
upright  bar  carried  over  the  head,  with  a 
swivel  piece  to  which  is  attached  the  straps 
to  be  passed  under  the  occiput  and  chin ; 
the  swivel  permittmg  the  rotation  of  the 
head.     See  Fig.  135. 

Fig.  135.  A,  the  body  of  the  brace  ;  B, 
the  upright  bar  curved  to  pass  over  the 
head,  and  sustained  in  a  strong  leather 
sheath  attached  to  the  upper  and  lower 
€ross  bands  of  the  body  brace.  A  back 
view  is  given  of  the  entire  apparatus. 

These  spinal  supports  should,  under  all 
circumstances,  be  worn  night  and  day  — 
thus  to  obviate  pressure  upon  the  spinal 
cord. 


350  OrthopjEdia. 

In  the  treatment  of  the  extraordinary  painful  condition,  often 
preceding  caries  of  the  last  cervical  and  first  dorsal  vertebrae,  the 
spine  supporter  (Fig.  135)  affords  much  relief  by  steadying  the  head 
from  the  bases  of  support  upon  the  ilium  when  the  patient  is  in  the 
erect  position  ;  thus  enabling  him  to  have  the  benefit  of  open  air 
exposure,  and  by  no  means  interfering  with  the  aplication  of  other 
means  of  relief,  as  the  bar  supporting  the  head  is  sustained  in  posi- 
tion some  distance  from  the  spine. 

5. 

Ext.  bellad 3j. 

Aq.  font ^  viij 

M 

Ft.  lotio. 

Cloths  wet  in  the  above  lotion  and  applied  to  the  affected  parts^ 
(extending  a  few  inches  on  either  side),  with  the  support  applied, 
often  afford  immediate  relief  for  the  time  being,  and  must  conse- 
quently be  frequently  saturated  with  Wia  lotion.  Cantharidal  vesi- 
cation, followed  by  poulticing  for  forty-eight  hours,  the  support 
removed,  and  the  patient  reclining  for  a  time,  is  the  most  valu- 
able, means  of  relief  in  obstinate  cases  as  it  relieves  the  congested, 
vessels  of  their  serum.  Even  this  decided  treatment,  however,  will 
not,  in  some  cases,  afford  immediate  relief;  the  liq.  potass,  arsen- 
itis,  is  then  the  most  reliable  remedy  in  doses  of  four  drops  three 
times  a  day  for  a  child  of  four  years  of  age,  and  to  older  children  in 
proportion.  For  several  weeks  after  a  patient  has  been  relieved  of 
the  painful  symptoms,  a  slight  jar  will  induce  a  recurrence  of  the 
suffering,  tending  frequently  to  a  more  persistent  condition  ;  leav- 
ing him  in  a  state  of  such  extreme  sensitiveness  that  great  difficulty 
is  experienced  in  the  removal  of  the  clothing.  The  early  applica- 
tion of  the  brace  and  head  support  protects  the  patient  from  much 
suffering,  especially  if  the  child  is  to  be  conveyed  any  distance  in  a. 
railroad  car,  otherwise  much  suffering  would  be  induced.  With 
the  brace,  however,  the  little  patient  can  ride  with  comparative 
comfort.  Another  peculiarity  in  the  ailment  is  that  of  an  obscure 
condition,  in  some  cases,  for  several  months,  rendering  the  diag- 
nosis doubtful.  Several  cases  of  more  than  ordinary  interest  have 
been  found  in  this  condition  of  the  ailment  after  having  been  care- 
fully examined  by  experienced  surgeons  without  a  discovery  of  the- 


Diseases  of  the  Bones.  351 

actual  condition  of  the  patients  having  the  premonitory  symptoms 
of  caries  in  the  last  cervical  and  first  dorsal  vertebrae. 

Maggie ,  a   little  girl,    four  years  of  age,  in  charge  of  hei 

grandmotherj —  the  mother  being  dead  —  the  family  possessed  of  con- 
siderable wealth,  had  been  presen  ted  for  advice  before  the  first  talent 
in  the  profession,  without  obtaining  a  reliable  diagnosis  as  to 
the  pathological  condition  of  the  patient,  or  of  finding  any  relief  for 
the  suffering  girl.  The  grandmother's  statement  was  to  the  effect 
that  some  three  months  previously  the  child  complained  of  the 
nurse  hurting  her  while  being  dressed  — giving  her  severe  pain  in 
the  back  of  the  neck.  After  this  complaint  had  been  made  some 
two  or  three  weeks,  the  grandmother  tapped  the  child  gently  uj)on 
the  shoulder,  at  which  she  cried  most  pitifully  from  the  suffering 
induced  by  this  playful  intention.  From  that  time,  it  was  observed 
that  to  lift  the  child  under  the  arms  would  give  her  great  pain  and 
suffering  for  an  hour  or  two ;  and  she  appeared  to  be  subject  to 
periodical  seizures  of  this  suffering  without  any  apparent  cause. 
The  suffering  had  become  so  extreme  that  ansesthetics  had  been 
resorted  to  for  relief  on  occasions  of  examining  her  condition.  By 
the  advice  of  their  family  physician  the  child  was  placed  under  our 
care  for  professional  treatment.  From  having  seen  several  other  cases 
quite  similar  in  indication,  we  placed  the  child  under  treatment  for 
caries  of  the  last  cervical  and  first  dorsal  vertebrae.  The  grand- 
mother objected  most  strenuously  to  the  application  of  the  brace, 
and  was  sustained  in  her  objections  by  several  of  the  medical  gentle- 
men who  had  previously  examined  the  child.  The  father  of  the 
child,  however,  insisted  upon  the  treatment  being  tried,  as  all  others 
had  failed,  and  contended  in  favor  of  the  brace  that  it  would  steady 
the  child's  head  and  neck  —  as  he  had  observed  that,  in  certain 
movements  of  the  head  this  suffering  was  induced.  The  child  was 
of  lymphatic  temperament;  blue  eyes  and  liglit  hair ;  suffering  at 
times  from  aphthous  ulceration  of  the  fauces  and  bleeding  from  the 
gums.  Tlie  teeth  Avere  short  and  discolored.  Even  after  all  her 
suffering,  the  child  was  rotund  in  form  ;  being  evidently  of  a  scor- 
butic diathesis,  or  strumous  inflammation  without  tubercle. 

Treatment;  emplastrum  lyttae  vesicatorum,  4x5  inches  was 
applied  to  the  cervical  region  extending  down  the  back  two  inches 
at  ten  o'clock  at  night,  and  to  be  carefully  dressed  in  the  morning 
with  a  large  flaxseed  poultice ;  the  dressing  being  changed  every 
four  hours  fur  forty-eight  hours.    Of  "  Fowler's  solution  "  of  arsenic, 


352  Orthop^¥.dia. 

four  drops  were  given  morning,  noon  ani  night ;  to  be  continued 
for  ten  days  unless  nausea  was  induced.  After  three  days  the  brace 
vvas  applied,  and  without  giving  pain  to  the  child.  The  nurse  was 
cautioned  to  keep  the  brace  on  the  child  day  and  night,  and  not  to 
permit  her  to  receive  a  jar  by  getting  down  from  chairs,  or  in  any 
other  manner.  After  ten  days'  treatment,  the  child  was  yet  subject 
to  suffering  from  slight  causes,  but  was  much  relieved  from  her 
former  condition  by  the  support  given  the  head,  so  much  so  as  to 
cause  her  to  tell  the  nurse  that  she  must  not  take  the  brace  off,  for 
it  relieved  her  pain.  It  was  then  thought  advisable  to  blister  again, 
and  to  increase  the  dose  of  arsenical  solution  to  five  drops  three 
times  a  day,  when,  on  the  second  day,  much  nausea  was  induced 
and  the  remedy  discontinued.  To  the  great  alarm  of  the  family, 
the  little  patient  was  now  becoming  partially  paralyzed,  and  in  one 
month  from  that  time  she  had  complete  paraplegia ;  the  neuralgia 
entirely  subdued,  and,  upon  removing  the  head  brace,  the  chin  and 
head  would  rest  upon  the  sternum;  but  upon  reapplying  the  sup- 
port, no  unusual  posterior  projection  of  the  spine  could  be  dis- 
covered. The  father  of  the  child  wished  me  to  continue  my 
attendance,  as  he  was  assured  that  others  had  recovered  the  power 
in  their  limbs  when  similarly  conditioned;  that  the  paralysis  was 
from  the  advanced  condition  of  the  caries  and  impairment  sustained 
from  the  long  continued  inflammation  that  was  now  subdued.  The 
following  mixture  was  then  ordered,  and  administered  teaspoonful 
doses,  night  and  morning : 

^. 

Hydrarg.  bichlorid grs.  ij. 

Tr.  cinchon.  comp |  vj. 

^. 

•    Ft.  mist. 

Plain  nutritious  diet  was  given  at  stated  periods,  and  fruit  in  the 
forenoon,  two  hours  before  taking  a  I'egular  meal.  Her  legs  were 
manipulated  at  least  twice  a  day  by  firmly  grasping  and  pressing 
tlie  muscles,  then  the  body  sponged  with  water  at  the  temperature 
of  80°,  and  well  rubbed  off  with  a  coarse  towel.  The  child  was 
lifted  to  her  feet  at  frequent  intervals  during  the  day  and  encouraged 
to  make  efforts  to  stand,  and  on  spastic  trism  being  observed  per- 
mitted to  rest  upon  her  limbs  as  much  as  possible.  Out  door  expo- 
sure on  all  favorable  occasions  was  made  available.     Three  months 


Diseases  of  the  Bones.  353 

passed  without  improvenieat  in  walking ;  the  sustaining  bar  of  the 
head  brace  was  then  shortened  half  an  inch,  that  the  bodies  of  the 
vertebrae  might  be  brought  into  closer  approximation  (an  important 
point  to  be  observed  in  spinal  supporters.  If  much  of  the  cancel- 
lated structure  of  the  bodies  of  the  vertebrae  is  absorbed  anchylosis 
cannot  readily  take  place  to  close  up  the  intervening  space  which  is 
the  case  in  advanced  cases  of  caries  of  the  spine ;  a  projection  being 
unavoidable  to  a  cure,,  and,  as  far  as  they  have  taken  place,  cannot 
be  interfered  with  without  endangering  the  patient's  power  of 
locomotion.  And,  what  is  remarkable,  this  holds  good  for  any 
portion  of  the  spinal  column ;  that  the  projection  cannot  be  inter- 
fered with  to  straighten  with  impunity).  The  little  patient  then 
commenced  to  improve  by  bearing  weight  upon  her  legs  when  in 
the  erect  position,  and  in  fifteen  months  was  restored  to  the  full 
and  free  use  of  her  limbs;  a  slight  angular  projection  having 
resulted  from  the  lowering  of  the  head  brace. 

In  all  cases  tending  to  caries  of  the  spine,  the  first  indication  to 
be  met  is  an  arrest  of  motion  by  lateral  support,  which  tends  to  the 
arrest  of  inflammation ;  and  if  it  has  tended  to  absorption  of  the 
intervertebral  substance,  angular  projection  will  be  observed.  But 
a  more  favorable  diagnosis  presents  in  the  early  stage  of  the  ailment 
if  the  patient  when  lifted  from  under  the  arms,  the  projection  dis- 
appears, there  is  a  prospect  of  cure  without  any  apparent  projection 
remaining.  This,  however,  is  only  in  cases  where  the  inflammation 
has  been  of  short  duration  and  a  very  limited  portion  of  the  bone 
removed,  admitting  of  being  bridged  over. 

All  spinal  braces  admitting  of  motion  to  the  spine,  evidently  per- 
mit attrition  of  the  diseased  vertebrae  upon  each  other,  and  cannot 
be  considered  as  complete  in  rendering  relief,  as  those  arresting  all 
motion  by  lateral  support.  Such  extension  as  is  given  by  crutches 
to  elevate  the  body  from  pressure  under  the  arms  should  be  avoided. 
This  means  of  elevating  the  body,  in  advanced  cases,  separates  the 
sound  portions  of  the  bodies  of  the  vertebrae,  and  prevents  anchy- 
losis from  completing  a  cure;  as,  in  cases  when  anchylosis  has  made 
some  progress,  and  angular  projection  is  very  apparent,  attempts  to 
overcome  the  projection  by  efibrts  at  extension  of  the  spine  have,  in 
many  instances,  produced  paralysis. 

Yet,  there  are  practitioners  who  boast  of  straightening  the  spine 
in  such  cases,  and  who  we  know  have  produced  paralysis  by  their 
efforts —  the  injured  subjects  now  living.     The  patient  having  been. 


354  Orthop^dia. 

placed  ia  such  position  as  to  give  the  deformity  the  greatest  promi- 
nence, a  plaster  cast  is  taken  of  the  deformed  portion  of  the  body. 
This  serves  to  determine  the  improvement  that  may  he  made  in  a 
very  brief  period  of  time.  The  next  step  in  the  proceduj-e  is  to 
place  the  patient,  face  doAvnward,  on  a  sofa  or  i3rm  mattress;  then 
reduce,  if  possible,  the  projecting  portion  of  the  spine,  and  apply, 
most  commonly,  a  patented  brace.  After  a  few  days,  the  patient 
being  placed  in  the  most  favorable  position  to  represent  their  im- 
proved condition,  another  cast  is  taken.  These  casts  are  preserved 
for  the  deception  of  others  that  may  be  so  unfortunate  as  to  fall 
into  their  hands  for  treatment.  The  paralyzed  patients  are  not 
noticed  in  the  history  of  the  extraordinary  successful  treatment. 

Indifference  in  the  profession  to  the  treatment  of  ailments  that 
they  are  not  familiar  with,  favors  these  charlatans  in  their  nefarious 
conduct,  resulting  in  great  injury  to  the  decrepit,  who  are,  in  many 
instances,  advised  by  their  family  physician  to  apply  to  these  crea- 
tures for  treatment.  But  most  commonly,  in  distant  parts  of  the 
country,  the  poor  cripple  having  excited  the  sympathy  of  the  post- 
master, who  is  supplied  with  circulars  filled  with  wood-cuts  and 
descriptions  of  extraordinary  cures,  receives  one  of  these  from  him, 
in  common  with  every  other  cripple  in  the  neighborhood.  This  is 
a  most  profitable  source  of  income  to  these  wretches,  flourishing 
upon  human  affliction,  which  they  only  serve  to  increase.  The  sad 
history  of  these  impositions  are  almost  daily  related  by  the  afflicted 
when  making  application  to  the  Hospital  for  the  Relief  of  the  Eup- 
tured  and  Crij^pled  for  treatment  for  themselves  or  their  children ; 
having  paid  all  they  could  obtain  from  their  friends,  in  addition  to 
that  of  their  own  hard  earnings,  for  a  few  weeks'  treatment,  when 
they  were  coolly  informed  that  if  they  could  remain  longer  they 
would  be  cured  —  after  having  been  informed  in  the  first  place  that 
they  could  be  cured  in  the  brief  period  for  which  they  had  paid, 
Avhen  most  of  them  had  chronic  ailments  that  would  require  years 
of  skilful  treatment  —  as  that  of  dental  paralysis,  extraordinary 
cases  of  diseased  joints,  lateral  curvature  and  caries  of  the  spine. 

The  advanced  stage  of  caries  of  the  spine  presents,  probably,  the 
least  assurance  of  successful  treatment  of  any  of  the  diseases  of 
the  bones,  as  removal  of  the  diseased  bone  cannot  be  made  available 
to  the  cure.  Large  abscesses,  as  before  stated,  form,  and  travel  in 
vai'ious  directions,  some  much  more  serious  than  others,  and  all  of 
doubtful   character  as  to  an  arrest   of  the  exhausting  influences 


Diseases  of  the  Bones.  365 

upon  the  vital  energies  of  the  system,  which  are  seriously  comprom- 
ised under  the  most  favorable  circumstances  —  the  obscurity  and 
almost  unlimited  mass  of  matter  accumulated  within  the  body 
impoverishing  th6  system  and  making  an  unfavorable  impression 
upon  the  assimilating  process  of  nutrition,  thus  impairing  the  very 
sources  upon  which  reliance  may  be  placed  for  recuperative  power. 
Hectic  symptoms,  even,  are  noticed  in  many  cases,  before  the  open- 
ing of  those  monster  abscesses,  commonly  known  as  psoas  and  spinal 
abscesses — having  descended  over  the  surface  of  the  psoas  muscles 
and  presented  in  the  groin,  often  passing  down  the  thigh,  enlarging 
it  to  a  size  nearly  equaling  two  of  the  sound  limb.  These  abscesses 
present  at  diflFerent  parts  of  the  body,  and,  in  some  cases,  in  the 
immediate  region  of  the  caries,  almost  always  tending  externally, 
and  progressing  in  size  very  slowly,  with  little  or  no  pain  in  most 
instances.  In  some  cases  abscess  is  formed  before  any  of  the  other 
signs,  except  weakness  of  the  spine,  and  before  deformity  has  taken 
place.  In  cases  when  much  pain  has  attended  caries,  as  is  remarked 
by  Mr.  Stanley,  th©  pain  and  irritation  cease  when  the  abscess  forms. 

Any  thing  like  a  satisfactory  prognosis  is  impossible  under  such 
circumstances.  Physical  signs  excite  suspicion  that  an  abscess  is 
forming  ;  the  pulse  more  tense  and  quick,  an  increase  of  tempera- 
ture attended  with  occasional  chills,  hectic  flush  of  the  cheek,  and, 
on  making  slight  exertion,  a  peculiar  whiteness  about  the  nose  and 
mouth,  with  great  increase  of  the  interruption  in  breathing  ;  a  dis- 
position, at  night,  to  fold  the  thighs  upon  the  abdomen,  with  the 
face  brouglit  down  almost  to  the  knees,  thus  relaxing  the  abdominal 
muscles  and  obviating  pressure  upon  the  viscera  that  would  press 
the  abscess  from  ordinary  tenseness  of  the  muscles  ;  an  unusual  full 
appearance  of  one  inguinal  region,  and  a  disposition  to  flex  the 
thigh  in  walking,  as  in  advanced  hip  disease  —  all  indicate  the 
approaching  development  of  the  abscess  in  the  groin. 

The  patient  being  assisted  to  the  erect  position  when  these  indi- 
cations present,  by  careful  observation  from  percussion,  fluctuation 
will  be  discovered,  and,  in  a  few  days,  the  abscess  development  will 
bo  observed,  when  a  roller  should  be  applied  about  the  hip  so  as  to 
give  support  and  pressure  —  limiting,  if  possible,  the  increasing- 
development  of  the  sac.  By  this  means  a  farther  develojoment  is,  in 
many  cases,  arrested,.and  even  a  diminishing  of  the  contents  occa- 
sioned, to  the  degree  of  entire  absorption.  The  child's  physical 
condition  having  been    favorably  maintained  —  a  precaution  that 


356  Orthop^dia. 

eliould  be  most  carefully  enforced  by  the  advice  of  the  surgeon,  from 
the  early  premonitory  indications  of  disease  of  the  spiue.  It  is  a 
wasting  disease,  and  requires  preparatory  measures  to  sustain  the 
exhausting  influence  upon  the  system  —  observable  by  the  experi- 
enced practitioner  in  medicine  when  there  is  not  an  externa-1  sign,  as 
that  of  projecting  sjDinous  process,  or  developing  abscess.  In  caries, 
alone,  when  abscess  is  not  induced,  prescribed  regime  and  on  arrest 
of  motion  in  the  diseased  locality  is  of  vital  Importance  in  the  arrest 
of  caries  in  its  iucipiency :  thus  saving  the  patient  from  sad  deform- 
ity and  general  impairment  of  health. 

To  the  opening  with  knife,  trocar,  or  caustic,  we  are  decidedly 
opposed  at  any  stage  of  these  spinal  abscesses,  and  we  are  not  alone 
in  our  opposition  to  the  interference  with  the  immense  collection  of 
serum  which  is  not  Inimical  to  the  health  of  the  patient,  if  absorbed. 
Mr.  T.  Holmes,  in  his  work  on  the  "  Surgical  Treatment  of  the 
Diseases  of  Infancy  and  Childhood,"  p.  543,  says:  "With  regard  to 
the  opening  abscesses  connected  with  spinal  disease,  my  own  expe- 
rience leads  me  to  dissuade  it.  However  affected,  and  with  what- 
ever precaution,  I  think  it  generally  does  more  harm  than  good. 
There  are,  of  course,  some  cases  where  the  rapid  increase  of  the 
quantity  of  fluid  and  the  pain  which  it  causes  compel  the  surgeon 
to  interfere  ;  and  then,  the  abscess  should  be  tapped  with  a  trocar, 
the  opening  being  closed,  or  Mr.  Seister's  method  of  dressing  the 
opening  with  carbolic  acid  should  be  used.  If  the  surgeon  prefer  to 
use  Thompson's  canula,  by  which  the  abscess  is  opened  under  water, 
there  can  be  no  objection.  I  have,  myself,  little  confidence  in  any 
of  these  plans,  and  greatly  prefer,  when  possible,  to  leave  the  mat- 
ter to  find  its  own  way  to  the  surface."  Mr.  Erichsen  remarks: 
*' When  abscess  has  formed  the  surgeon  should  be  in  no  hurry  to 
open  it;  but,  in  accordance  with  the  principles  laid  down  when 
treating  of  this  affection,  he  should  delay  doing  so,  lest  injurious, 
fatal  constitutional  irritation  be  set  up."  Mr.  Holmes  Coote,  in  his 
work  on  joint  diseases  (p.  159),  says  :  "  It  is  in  such  cases  that 
large  abscesses  are  so  apt  to  form,  either  pursuing  the  course  of  the 
psoas  muscle  and  presenting  in  the  thigh,  constituting  a 'psoas 
abscess,'  or  forming  behind  the  tendinous  origin  of  the  transver- 
sali?  muscle  and  presenting  in  the  loins,  constituting  a  lumbar 
abscess. 

"  When  there  is  an  apparent  necessity  for  opening  the  abscess, 
let  not  the  surgeon  act  hastily !      That  pus  may  become  inspissated 


Diseases  of  the  Bones.  357 

by  absorption  of  its  watery  elements  is  acknowledged  by  the  latest 
pathologists ;  that  it  may  be,  and  often  is  removed  by  the  absorb- 
ents is  my  firm  belief.  The  gradual  disappearance  of  a  large  col- 
lection of  pus  is  an  event  by  no  means  rare  in  surgery." 

When  the  prognosis  is  clear  that  spinal  abscess  has  ensued,  from 
apparent  development,  or  otherwise,  every  possible  means  must  be 
made  available  toward  invigorating  the  patient;  and  it  is  quite 
possible  in  the  majority  of  cases  to  greatly  increase  their  vital  ener- 
gies. To  the  accomplishment  of  this  very  desirable  object,  pleasing 
entertainment  at  home  or  abroad,  in  the  open  air  as  much  as  pru- 
dence will  admit  of  in  regard  to  weather,  and  well  ventilated  sleep- 
ing apartments  should  be  secured.  A  perfect  discipline  should  be 
observed  as  to  taking  food  of  nutritious  quality  in  proper  quantity  — 
not  quite  satisfying  the  appetite  —  and  at  stated  periods.  Fruit  to 
be  taken  only  in  the  forenoon,  and  at  most  two  hours  after  or  before 
meals.  Fluids  to  quench  the  thirst  should  be  taken  in  exceedingly 
small  quantities,  and  at  no  time  for  at  least  an  hour  before  meals,. 
and,  if  possible,  only  at  meals.  This  is  a  general  view  of  a  suitable 
regime,  to  be  modified  and  determined  in  detail  by  the  attendant 
surgeon.  And,  as  before  stated,  every  effort  should  be  made  to 
compress  the  developing  abscess  by  rollers,  or  lacings,  over  cotton 
batting,  applying  to  the  surface,  and  twice  a  day  the  following 
embrocation :  — 

Lin.  sapo.  camph |  yj 

Tr.  iodini. 

Tr.  belladon aa  |  j 

01.  cajeput 3  J 

Ft,  emb. 

The  abscess  should  be  carefully  bathed,  previous  to  each  applica- 
tion of  the  embrocation,  with  warm  water  containing  a  drachm  of 
common  carbonate  of  potash  to  the  quart,  and  diluted  if,  in  some 
cases,  too  caustic.  This  solution  affords  much  relief  to  distended 
abscesses  when  located  about  the  body  or  limbs.  A  napkin  or  other 
soft  material  folded  and  kept  moist  with  water  should  be  applied  to 
the  affected  part,  when  so  sensitive  as  not  to  admit  of  compression. 
When  in  this  condition,  inflammation  is  not  only  confined  to  the 
abscess,  but  involves  to  a  considerable  extent  the  surrounding  soft 


358  Orthop^dia. 

tissues,  attended  with  increase  of  temperature  and  severe  pain.  Por 
relief  ttie  evaporating  lotion  containing  chlorate  of  ammonia,  as 
before  described,  should  be  freely  applied  to  the  parts.  Decided 
constitutional  treatment  is  now,  if  not  enforced  earlier,  imperative 
to  the  safety  of  the  patient,  and  invites  a  careful  investigation  of 
the  materia  medica  and  its  therapeutic  tendencies  to  the  resuscita- 
tion of  organic  vigor,  to  that  of  active  assimilation,  demanding  an 
increase  of  nutrition  to  sustain  the  excessive  drain  that  is  now 
about  to  take  place. 


CHAPTER  XI Y. 

TONICS,  AND  THEIK  EFFECT  UPON  THE  SYSTEM. 

Wlien  Tonics  are  admissible  or  inadmissible.  —  Modus  operandi  of  Tonics  on 
the  system,  —  Torpidity  established  from  inability  to  move  about  or  compul- 
sory confinement.  —  Physical  condition  of  the  patient  determines  the  thera- 
peutic agents  to  be  used.  —  Tonics  materially  increase  the  vital  forces,  if 
judiciously  administered.  — Abscesses  may  become  incurable  —  Selection  and 
QUALITIES  OF  ToNics. —  Exhilarating  influence  as  a  Tonic.  —  Pure  Air  as  a 
Tonic.  —  Modifying  Influences. —  Well-ventilated  apartments. —  Tempera- 
ture as  a  Tonic.  —  Medicinal  agents  as  Tonics.  —  Treatment  of  chronic 
inflammation.  —  Diet.  —  Method  of  relieving  the  nerves  and  congestion  of  the 
bloodvessels  —  Means  whereby  inflammation  is  extended  throughout  the 
system.  —  Alterative  treatment.  —  Application  of  Tonics  to  the  various 
ailments  treated  in  this  work. 


There  are  conditions  of  the  system  when  tonics  are  inimical,  as 
in  cases  of  low  degree  of  excitability,  or  deficiency  of  constitutional 
stamina,  or  from  the  abnse  of  stimulants.  They  tend  to  increase 
the  depression  by  an  exhausting  influence  —  there  being  a  defici- 
ency of  no  latent  power  to  excite  into  renewed  action. 

Tonics  are  inadmissible  in  indirect  debility,  as  in  an  overwhelm- 
ing congestion  or  inflammation  of  some  important  organ  or  tissue, 
there  being  such  a  concentration  of  blood  and  nervous  force  in  one 
part  that  there  is  insuflBcient  elsewhere  to  support  the  systemic 
actions  generally,  or,  the  organ  affected  is  restricted  so  as  to  arrest 
its  function  and  thus  prostrate  all  dependent  functions.  Derivatives 
and  diffusion  of  excitement  are  the  remedies  in  such  cases. 

Tonics  are  only  indicated  as  beneficial  in  cases  of  depression  and 
debility,  in  which  the  excitability  has  not  been  exhausted  by  pre- 
vious excessive  exhaustion,  in  which  the  depression  is  neither  the 
result  of  active  congestion  or  irritation,  nor  sudden  and  transient 
as  to  call  for  stimulation  more  prompt  than  that  which  character- 
izes this  class  of  remedies.  Hence,  they  are  most  serviceable  in  slow 
impairment  of  health  as  in  that  of  ordinary  chronic  ailments. 


360  Or  thop^dia  . 

As  to  the  modus  operandi  of  tonics  on  the  system,  there  is  no 
well  determined  conclusion  ;  satisfactory  results  are  well  determined, 
and  upon  this  we  must  rest  satisfied  for  the  present.  They  are  not 
primary,  but  secondary;  the  system  must  be  in  a  suitable  condition 
to  be  benefited  by  their  use.  They  appear  to  act  chiefly  on  the 
aigestive  organs;  they  promote  the  appetite,  invigorate  digestion, 
create  a  desire  for  more  food  to  be  eaten,  and  more  thoroughly  pre- 
pared for  absorption  and  assimilation,  and  thus  enrich  the  blood; 
rendering  it  at  once  more  stimulating  to  the  functions  and  nutri- 
tion, exciting  general  tonic  efi"ects  upon  the  system  at  large,  and 
when  alterative  medicines  are  combined,  greatly  correct  or  modify 
morbid  secretions.  How  they  afiect  the  ultimate  organic  constitu- 
ents of  the  body  is  conjectural.  They  have  been  found  by  chemical 
investigation  in  the  midst  of  the  tissues.  It  is  thought  probable 
that  each  distinct  function  is  performed  through  the  instrumental- 
ity of  a  special  power  in  the  ultimate  organic  cells,  nuclei,  or  mole- 
cules of  the  organ,  and  that  tonics  operate  simply  by  stimulating 
this  power  into  a  somewhat  increased  activity.  That  there  is  a  cer- 
tain vital  cohesion  essential  to  the  due  performance  of  the  function, 
and  that  tonics  are  moderate  stimulants  to  this  cohesion,  is  a  reason- 
able conclusion.  As,  to  this  action,  may  be  ascribed  the  great 
firmness  of  the  tissues  especially  from  the  stimulant,  the  cause 
ceases  and  the  system  is  left  in  a  condition  in  which  it  can  repair 
itself  and  resist  the  local  irritant  that  is  temporarily  exhausting  the 
system. 

We  have  torpidity  established  from  inability  to  move  about  —  con- 
fined to  a  room  —  severe  pain  induced  by  motion  and  the  surround- 
ing monotonies.  A  child  with  morbus  cosarius,  or  paralysis  from 
caries  of  the  spine,  whose  parents,  greatly  grieved  at  its  condition, 
are  from  day  to  day  entering  the  room  with  an  unmistakable  bearing 
of  grief,  soon  becomes,  as  it  were,  partially  paralyzed ;  an  apparent 
habit  of  insufficient  action  has  been  established,  which  the  inherent 
force  of  the  system  canuot  throw  oflF,  and  it  is  disposed  to  continue 
m  the  condition  in  which  it  may  have  compulsorily  continued  for  a 
considerable  time.  Here  we  have  a  torpidity  of  the  mental  and 
physical  condition  of  the  child,  upon  which  special  treatment  for  the 
ailment  under  the  circumstances  then  existing  can  make  no  impres- 
sion as  to  improvement,  or  even  toward  an  arrest  of  progress  to  death. 
By  giving  the  patient  a  change  in  the  way  of  inviting  scenery, 
tempting  its  thoughts  to  contemplate  something  more  than  its  owe 


Tomes  AXij  THEIR  Effect  upox  the  System.       3G1 

condition,  eyen  this  mental  exercise  will  stimulate  the  weakest  physi- 
cal organization  to  a  condition  of  susceptibility  favorable  to  the 
influence  of  tonics.  Here  we  perceive  that  home  seclusion  has  a 
pernicious  tendency;  rendering  treatment  unavailable  that  would 
relieve  the  patient  if  favorably  circumstanced,  as  he  would  be,  in  an 
institution  designed  for  the  purpose.  When  thus  situated  even  the 
most  gentle  tonic  would  become  a  potent  medicine,  and  essential  to 
excite  an  impulse  to  the  functions  of  assimilation,  or  that  of  a  par- 
ticular organ,  most  common  in  convalescence  from  acute  disease. 

General  depression  or  debility  may  result  from  the  torpidity  of  a 
particular  function  or  organ,  upon  which  impairment  the  general 
deficiency  may  react,  so  as  to  resist  treatment  for  abscess  or  ulcer. 
A  tonic  suited  to  the  condition  of  the  patient  would  not  only  favor 
the  treatment,  but  without  other  treatment  than  cleanliness  cure 
the  abscess  or  ulcer. 

The  patient's  physical  condition  determines  the  therayjeutic  agents 
to  be  prescribed,  with  a  special  consideration  of  the  expectation  of 
results.  The  impairment  of  the  physical  condition  of  the  patient 
from  extraordinary  supply  to  a  morbid  accumulation  of  pus  and 
serum,  demands  a  more  than  ordinary  supply  of  sustenance,  dej)end- 
ent  upon  an  increase  of  assimilating  power  or  functional  effort  to 
sustain  more  than  a  normal  condition  of  the  system.  This  must 
be  the  first  effort,  or  the  system  will  suffer  from  exhaustion.  The 
second  effort  is  to  correct  any  morbid  functional  condition  which 
may  be  favored  by  a  normal  tendency  when  the  system  is  in  a  con- 
dition to  assimilate  nutrition.  The  supply  of  nutritious  food  may 
be  all  that  could  be  desired,  but  the  functional  efforts  insufiicient  to 
meet  the  demand.  Then  the  indication  is  to  increase  the  organic 
function  of  assimilating  nutriment  to  a  recuperative  tendency. 

Tonics,  when  properly  prescribed  and  carefully  administered, 
tend  largely  to  an  increase  of  the  vital  forces  or  recuperative 
power ;  however,  there  is  no  medicine  in  the  materia  medica  that 
requires  more  practical  judgment  in  the  selection  and  use  than 
tonics.  If  improperly  used  they  induce  a  condition  of  indirect 
debility,  to  the  great  injury  of  the  patient.  By  giving  tone  is  to  be 
understood  as  giving  a  certain  vital  cohesion  of  the  living  mole- 
cules in  an  organized  tissue,  which  is  essential  to  the  due  perform- 
ance of  its  ofiBce;  an  augmentation  of  vital,  cohesive  tendency  to 
increased  energy  of  function,  and  thus  only  to  the  vital  capacity, 
which  has  a  limit.     If  called  into  excessive  action  it  is  proportion- 


362  Orthopjedia. 

ably  exhausted;  and  in  this  state  of  exhaustion  the  ordinary 
healthful  excitants  have  less  than  their  normal  effect,  and  depres- 
sion, therefore,  must  follow. 

Tonics  have  a  relative  capacity  to  the  improvement  of  the 
patient's  enfeebled  condition  and  their  suitable  selection  should  be 
limited  by  the  normal  vital  cajjacity.  This  view  obviates  the  infer- 
ence that  tonics  exhaust  and  de|)ress  the  system.  When  tonics  are 
properly  selected  they  moderately  and  durably  increase  the  vital 
action.  Strength  is  dependent  upon  the  normal  state  of  the  ulti- 
mate organic  constituents  of  the  tissues,  which  can  be  sustained  by 
a  due  degree  of  all  the  vital  processes  which  contribute  to  the 
nutrition  or  maintenance  of  parts,  and  tonics  have  the  property  of 
exciting  these  processes.  It  follows,  when  they  are  deficient,  and 
debility  has  ensued  as  a  result,  tonics  may  prove  not  only  excit- 
ants, but  strengthening,  providing  the  depressing  causes  have  not 
exhausted  the  excitability  of  the  organization. 

Abscesses  and  secretin g  ulcers  depressing  the  fanctional  condi- 
tion, tend  to  positive  debility,  and  in  degree  to  the  power  of  resist- 
ance from  stamina  of  the  system,  and  may  thus  become  incurable. 
They  can  only  be  considered  in  a  state  of  permanency,  however, 
when  they  overpower  the  vital  energy  of  the  system ;  and  if  timely 
aid  is  given  by  suitable  tonics  a  resisting  force  may  be  induced,  even 
to  the  recovery  of  the  patient,  by  exciting  the  depressed  functions 
and  strengthening  with  nutrition  the  debilitated  structures,  and 
long  before  the  excitability  through  which  they  operate  has  had 
time  to  suffer  materially. 


SELECTION  AND  QUALITIES  OF  TONICS. 
EXHILAEATIXG  IXFLUEXCE  AS  A  TOXIC. 

Favorable  surroundings  are  of  such  importance  as  to  ever  give 
promise  of  success  in  the  treatment  of  chronic  diseases.  The 
depressing  emotions,  as  those  of  despondency,  grief  and  fear,  are 
resisting  influences  that  will  render  the  most  skilfully  prescribed 
medicines  powerless  in  their  operation  as  to  the  improvement  of  the 
patient's  condition.  Whatever  in  any  manner  contributes  as  an 
elevating  influence  to  this  condition  of  the  feelings,  must  indirectly 
impart  tone  to  the  system,  and  although  negative   in  its  operation. 


ICONICS  AND  THEIR  EFFECT  UPON  THE  SYSTEM.  3G3 

must  rank  among  tonic  influences  to  the  mental  conditions,  such 
as  enlivening,  elevating  and  pleasurable  reflection,  inducing  an 
appreciation  of  the  beautiful  and  the  sublime  in  nature  and  art, 
tending  to  the  enjoyment  of  all  agreeable  exercises  of  the  intellec- 
tual faculties.  For  children,  instrumental  and  vocal  music  in 
concert,  the  patient  joining  in  the  exercise,  contributes  most  largely 
to  the  relief  of  depression  of  mind  arising  from  long  contii.ued 
monotonous  confinement.  Games  engaging  reflection  and  calcula- 
tion in  order  to  win,  are  also  useful,  though  this  amusement  must 
be  limited,  or  the  mind  will  become  fatigued,  if  of  a  sedative  char- 
acter. Games  engaging  physical  and  mental  energy,  modified  to 
the  child's  condition,  are  most  salutary.  Passive  exercises  exhaust 
physical  energy  without  a  compensatory  increase,  because  of  its 
sameness,  having  a  depressing  influence  upon  the  mind,  in  a  word, 
it  is  monotonous,  and  is  objectionable  from  being  so,  however 
pleasing  in  appearance.  Diversity  and  self-effort  is  essential  to 
afford  pleasure.  Whatever  is  pleasurable  to  our  mental  and  physical 
condition  is  a  stimulant,  and  if  limited  to  a  healthful  influence 
when  in  a  state  of  debility,  is  positively  tonic  and  restorative. 

After  a  careful  diagnosis  of  the  ailment  has  been  made,  the 
patient's  present  or  future  condition  for  treatment  is  to  be  carefully 
considered  and  prescribed  for,  and  in  ratio  to  the  fulfilment  of  the 
requirements  to  insure  a  state  of  social  enjoyment  to  the  patient, 
will  be  the  promjse  of  success,  there  being  a  sufficiency  of  vital 
energy  to  be  made  available  from  skilful  treatment  to  the  restora- 
tion of  the  patient. 

The  influence  of  the  mind  on  the  body  is  a  matter  of  common 
observation.  Reasonable  excitement  is  known  to. increase  the  entire 
energies  of  the  system,  as  is  evidenced  in  the  circulation  of  the 
blood,  tending  to  an  inci-ease  of  functional  activity  involving  nutri- 
tion and  a  desire  for  food,  hence  of  primary  importance  as  a  thera- 
peutic agent. 

PURE   AIR   AS   A   TONIC. 

Pure  air  is  an  invaluable  tonic,  and  systems  acqaire  renewed 
strength  through  the  healthful  agency  of  an  uncontaminated  atmos- 
phere, well  charged  with  electricity  —  the  latter  a  most  important 
consideration,  as  it  demands  a  careful  consideration  of  locality. 
When  static  electricity/  is  not  readily  attained  under  an  ordinary 
condition  of  favorable  weather,  depression  of  nervous  energy  pre- 


364  Orthop^dia. 

vails,  unfavorable  to  health.  Certain  localities  are  thus  conditioned, 
even  within  the  limits  of  the  radius  of  a  mile.  In  a  damp  locality 
the  excessive  evaporation  of  moisture  deprives  the  air  of  its  elec- 
tricity. The  electrical  machine,  to  obtain  electricity  from  the 
atmosphere  by  friction  and  accumulated  by  insulation,  readily  de- 
termines the  electrical  condition  of  the  atmosphere.  It  matters 
not  how  pure  the  air  may  be,  even  in  dry,  elevated  localities,  there 
are  extraordinary  conditions  of  the  atmosphere  at  times,  depriving 
the  animal  system  of  its  normal  quantum  of  energy — the  influence 
extending  to  brutes ;  their  depression  being  most  manifest.  They 
herd  together,  having  no  disposition  to  feed  or  to  be  aroused  from 
their  position.  This  influence  is  frea^uently  noticed  by  persons  wha 
are  wont  to  exclaim  at  such  times  :  "  What  a  depressing  influence 
there  is  to  day  !  I  feel  extremly  languid,  and  yet  the  thermometer 
only  indicates  80°."  This  condition  of  the  atmosphere  is  most 
depressing  only  a  few  hours  before  the  advent  of  a  thunder  storm^ 
at  which  time  not  a  spark  of  electricity  can  be  obtained  from  the 
electrical  machine,  and  in  many  instances  for  a  period  of  twelve 
hours.  After,  and  even  during  a  thunder  storm,  however,  electricity 
in  abundance  can  be  obtained,  and  the  animal  system  is  exhilarated; 
the  brutes  will  feed,  and  be  disposed  to  playful  exercise  —  the  tem- 
perature after  the  shower  indicating  80°  and  upwards.  This  depres- 
sing influence  is  most  worthy  of  notice,  as  it  is  continuous  in 
certain  localities,  audits  most  pernicious  influence  is  experienced  in 
low,  marshy  districts  of  country  and  in  which  exist  what  are  sup- 
posed to  be  malarious  diseases,  or  those  the  result  of  malaria,  the 
deficiency  in  electricity  not  being  considered. 

There  are  modifying  influences  that  can  be  made  available,  such 
as  those  of  carefully  ventilating  apartments  by  means  of  artificial 
heat,  supplying  patients  with  a  continuous  change  of  air,  and  avoid- 
ing excessive  velocity  that  would  exhaust  the  temperature  of  the 
body  more  rapidly  than  it  could  be  generated. 

TEMPERATURE   AS   A  TONIC. 

Temperature  as  a  tonic  influence  claims  special  consideration. 
Cold  is  directly  sedative,  and  serves  an  admirable  purpose  in  allay- 
ing local  inflammation,  under  careful  observation.  It  does  not,  for 
a  time,  lessen  power,  while  the  excitability  of  the  depressed  part  is 
increased  by  its  suspension  or  rest ;  the  consequence  is,  that  when 
removed,  the  normal  condition  assumes  an  excitement  beyond  its 


TONICH  AND  THEIR  EFFECT  UPON  THE  SYSTEM.  365 

former  state.  A  cold  breeze  of  air  is  exhilarating  and  tonic  in  effect 
as  a  negatiye  influence,  and  often  determines  a  stimulant  effect  to 
the  circulatory  system,  by  which  injury  is  obviated.  It  is  through 
the  operation  of  these  principles  that  reaction  follows  the  first 
impression  produced  by  cold.  This  reaction  is  not  confined  to  the 
part  first  impressed  alone,  but  extends  throughout  the  system. 
Cold  elevates  the  vital  functions  by  a  secondary  influence,  and  thus 
it  may  be  considered  a  tonic.  Local  and  general  debility  is  much 
relieved  by  a  judicious  exposure  to  cold  air  or  water,  and  is  one  of 
the  invigorating  influences  made  available  in  traveling,  when  we 
have  activity  tending  to  an  accumulation  of  strength.  But  here 
again  there  is  danger.  If  too  long  continued  it,  at  length,  exhausts 
vital  energy,  and  depression  follows  from  inefiiciency  of  excitability. 
If  in  excess,  as  regards  the  vital  energies,  it  rapidly  exhausts  excita- 
bility —  a  vital  organic  condition.  Eeaction  determines  the  avail 
ability  of  cold  to  the  recuperative  energy  of  the  system,  and  must  be 
most  carefully  observed  in  the  use  of  cold  baths.  Cold  must  be  care- 
fully considered  as  an  adjunct  in  the  restoration  of  strength  when 
there  is  a  tendency  to  congestion  of  the  brain  or  lungs,  or  disease 
of  the  heart.  The  first  impression  of  cold  to  the  surface  repels  the 
blood  to  the  internal  organs,  and  a  pre-existing  disposition  to 
engorgement  is  fearfully  compromised.  The  susceptibilities  of 
individuals  must  be  carefully  observed.  In  case  of  a  delicate  child 
having  a  local  excitement  in  a  joint,  great  care  must  be  taken  in  the 
application  of  volatile  fluids  or  spirits  to  the  part,  because  of  its 
rapid  evaporation,  and  exhaustion  of  the  vital  heat,  as  also  when 
applied  to  the  whole  body,  it  has  a  most  depressing  and  exhausting 
influence  if  reaction  does  not  follow  —  which  should  be  carefully 
noticed.  The  normal  temperature  being  in  direct  ratio  to  the 
ability  of  the  system  to  generate,  and  if  delicate  the  loss  is  irrepar- 
able because  of  the  depression  on  the  vital  forces. 

TREATMENT    OF    CHRONIC    INFLAMMATION". 

In  chronic  ailments,  as  that  of  local  inflammations  resulting  in 
the  dissolution  of  the  involved  tissues,  to  the  impairment  of  the 
•general  system  —  observable  in  cases  of  excessive  drainage  from 
open  abscesses  and  ulcers  —  the  pernicious  influence  appears  to  be 
-diminished,  elasticity  or  a  depressing  of  vital  cohesion  from  exhaus- 
tion. Normal  organic  function  is  impossible,  because  of  deficiency 
an  nutrition  from  excessive  demand;  the  assimilating  process  being 


366  Oe  thop^edia. 

fclius  impaired,  and  the  remedying  of  extraordinary  excitement  tend- 
ing to  increase  the  vital  forces,  wliich  is  done  at  the  expense  of 
exhausting  excitability,  if  extraordinary  recuperative  power  is  not. 
induced.  Tonic  medicines  do  not  act  directly  upon  the  physical 
organization,  but  slowly  through  the  vital  functions  as  excitants, 
A  proper  cohesion  of  the  living  molecules  in  organized  tissues  is 
essential  to  the  performance  of  normal  functions,  and  a  moderate 
augmentation  of  this  vital  cohesion  may  give  increased  energy  to- 
the  function.  It  is  simply  through  the  vital  powers  that  the  several 
constituents  of  the  body  are  enabled,  under  the  influence  of  certain 
excitants  to  perform  their  functions  duly,  and  extraordinarily,  to  the- 
arrest  of  inimical  influence,  which  is  the  tendency  of  the  vital 
powers  when  sustained  in  energy.  Tonics  have  no  inherent  quali- 
ty of  strength  that  can  be  imparted  to  the  tissues ;  they  are  excit- 
ants having  special  tendencies  that  demand  of  the  practitioner 
careful  consideration  in  their  selection  to  meet  the  carefully  diag- 
nosed indications  of  deficient  energy  of  certain  organic  functions^ 
and  the  extent  of  excitement  the  organs  will  bear  without  exhaus- 
tion or  being  overpowered  by  the  excitant,  or  excess  of  excitants 
There  being  a  normal  standard  of  excitability  in  each  individual^ 
the  capacity  must  be  carefully  considered,  as  well  as  its  relative  con- 
dition when  impaired  by  disease.  Excesses  from  medication  often 
do  more  injury  than  can  be  readily  conceived  of,  especially  when 
the  friends  of  the  patient  are  constantly  insisting  on  having  more 
done  than  tlie  system  will  bear.  In  hospital  practice  the  practi- 
tioner can  offer  no  reasonable  excuse  for  excessive  medication,  and 
hence  the  greater  advantage  to  the  patient  from  the  practical 
experience  of  the  skilful  surgeon.  So  tlie  judicious  use  of  tonics  in 
the  treatment  of  chronic  disease  can  only  be  determined  by  a  long; 
career  of  vigilant  observation  upon  variously  conditioned  patients,, 
and  this  knowledge  only  obtainable  under  the  most  favorable  cir- 
cumstances, not  attainable  in  private  practice,  because  of  the  indis- 
creet interference  and  inadvertent  neglect  usually  attending  practice 
in  private  families. 

The  sequence  of  chronic  inflammation  is  most  commonly  that  of 
abscess  and  ulceration.  This  invites  attention,  first,  to  that  condi- 
tion of  inflammation  that  predisposes  to  these  results;  an  inflam- 
mation under  peculiar  circumstances  of  health.  As  Mr.  Erichsen 
remarks:  '"'For  the  same  treatment  that  would  arrest  inflammation 
in  one  form  of  the  disease  would  certainly  favor  its   progress  in 


Tonics  and  their  Effect  upon  tjte  System.       367 

another."  We  do  not  have  chronic  inflammation  in  a  healthy  per- 
son ;  it  is  the  resnlt  of  some  dyscrasia  of  the  system,  and  that  gov- 
erns the  treatment;  as  in  cases  where  actual  depletion  is  inadmis- 
sible, as  it  would  increase  the  sesthenic  condition  of  the  patient.  In 
these  cases  judicious  treatment  is  not  that  intended  to  produce  a 
great  and  sudden  impression  on  the  system,  as  we  are  requii-ed  to  do 
in  the  treatment  of  the  acute  condition.  Attention  to  nutrition 
must  be  given  in  chronic  inflammation,  wJiich  can  only  be  arrested 
to  a  tolerable  condition  by  close  attention  to  all  the  circumstances 
that  tend  to  the  improvement  of  the  patient's  general  health,  as 
Avell  as  by  producing  a  favorable  impression  upon  the  part  itself,  by 
appropriate  local  means.  Hence,  in  the  treatment  of  chronic  in- 
flammation, hygienic  measures  are  of  primary  consideration.  In 
most  cases  nothing  can  be  done  without  a  proper  regime,  and  much 
may  be  done  by  it  that  could  not  be  effected  by  more  direct  medici- 
nal means.  This  is  our  reason  for  first  considering  those  available 
means  of  indirect  tonic  influences,  as  preparatory  means  for  a  more 
concise  view  of  general  principles  in  treatment,  than  was  originally 
stated  when  treating  upon  special  ailments,  such  as  morbus  coxa- 
rius,  synovitis,  and  caries  of  the  spine. 

In  the  treatment  of  chronic  inflammation,  the  diet  is  of  much 
consequence  as  to  the  quantity  and  quality  of  nourishment,  which 
must  be  carefully  proportioned  to  the  strength  of  the  patient,  and 
the  taking  of  food  carefully  limited  to  stated  periods,  so  as  to  afford 
ample  time  for  digestion ;  restricting  at  all  times  the  feeble  patients 
from  taking  of  fluids  bet\yeen  meals,  thus  to  prevent  the  dilution  of 
the  digestive  fluids  and  an  interruption  to  the  normal  process. 

In  the  more  active  form  of  chronic  inflammation,  farinaceous 
food,  with  milk,  may  be  allowed.  The  latter,  however,  is  not  suit- 
able if  the  patient  is  subject  to  acid  stomach  :  as  lactic  acid  is  most 
readily  formed,  and  is  a  decided  irritant  to  the  mucous  membrane 
of  the  stomach  ;  under  such  circumstances,  plain  broth  may  be  sub- 
stituted, with  that  of  carefully  prepared  bread. 

In  the  less  active  forms,  occurring  in  feeble  constitutions,  with 
depression  of  general  power,  animal  food  of  nourishing  quality  may 
be  given,  such  as  roasted  and  broiled  meats,  accompanied  with  sweet, 
well-baked  bread  of  a  day's  standing ;  milk  twice  a  day,  and  fruit 
two  or  more  hours  afterward,  but  not  in  the  latter  part  of  the  day. 
Mr.  Erichsen  has  truly  remarked :  '-'  Nothing  requires  greater  nicety 
in  practice  than   to  proportion  the  diet,  and   determine  the  cases 


368  Orthop^dia. 

in  which  stimulants  are  necessary."  It  may  he  stated  generally, 
that  the  more  the  disease  assumes  the  asthenic  and  i^assive  forms, 
the  more  are  stimulants  required  ;  until,  at  last,  in  a  truly  adynamic 
type,  our  principal  trust  is  in  these  agents,  and  large  quantities  of 
brandy  and  ammonia  are  required  to  maintain  life.  Brandy,  in  its 
raw  state,  is  too  much  of  an  irritant  to  the  stomach,  and  serves  a 
much  better  purpose  when  combined  with  milk  or  other  nutrient, 
as  that  of  bread  mucilage  —  stale  bread  having  boiling  water  poured 
upon  it,  strained  and  sweetened.  This  makes  a  pleasant,  nutritious 
beverage. 

As  favorable  hygiene  as  possible  having  been  obtained,  our  next 
effort  should  be  to  relieve  the  suffering  condition  of  our  patient. 
This  invites  attention  to  the  cause  of  pain.  Distention  and  pres- 
sure contribute  most  largely  to  this.  Kolliker,  Hasse,  Burch, 
Paget  and  Martin  Jones,  agree  that  there  is  a  dilatation  of  the 
blood-vessels.  The  phenomena  of  inflammation  appear  to  be  a 
stagnation  or  congestion  of  the  capillaries  from  dilatation  of  the 
arteries;  the  immediate  stagnation  taking  place  in  the  capillaries, 
which  are  not  in  a  direct  line  of  passage  from  an  artery  into  a  vein, 
and  the  arrest  taking  place  by  the  red  corpuscles  coalescing  by 
mutual  adhesion  into  masvses,  which,  after  being  carried  bodily  up 
and  down,  more  and  more  slowly,  at  last  appear  to  block  up  the 
vessel,  or  partly,  by  overcrowding  and  distending  it,  and  partly  by 
becoming  adherent  to  its  walls,  this  adliesion  usually  commencing 
at  the  angle  of  union  between  two  capillaries  around  the  stagnant 
part  of  the  vessel,  or  crowded  by  an  aggregation  of  the  red  cor- 
puscles, which  appear  to  be  more  closely  packed  in  consequence  of 
the  draining  away  of  the  liquor  sanguin.  The  blood  does  not  enter 
the  part  of  the  vessel  in  which  stagnation  has  taken  place,  but 
passes  off  by  a  collateral  branch.     (Martin  Jones.) 

One  of  the  most  prominent  symptoms  is  pain,  supposed  to  be 
partly  owing  to  increased  sensibility  of  the  nerves,  but  chiefly  to 
the  pressure  made  upon  their  terminal  branches  by  dilatated  blood- 
vessels, distended  mainly  by  an  excess  of  serum,  and  which 
manifests  itself  by  the  occurrence  of  pain.  The  condition  is  that 
of  involving  the  superficial  tissues,  redness,  swelling,  from  turges- 
ence  of  the  vessels,  cognizable  heat,  a  fulness  or  throbbing.  The 
indications  for  relief  appear  to  be  very  plain,  relief  to  the  congested 
condition  of  the  parts  primarily  affected.  The  indication  of  deeper 
seated   inflammation    not   presenting    the    superficial    appearance 


Tomes  AXD  THEIR  EFFECT  UPON  THE  SYSTEM.  309 

requires  the  same  means  of  relief;  it  is  of  the  same  pathological 
condition  affecting  the  deeply  located  tissues,  and,  as  yet,  not 
involving  the  superficial  integument,  as  when  abscess  is  forming 
This,  however,  does  not  always  follow,  although  its  destructive 
influence  may  be  very  great  as  will  be  noticed  as  the  results  of 
inflammation. 

Inflammation  in  its  primary  stage  may  be  arrested,  or  terminate 
without  interference,  leaving  no  permanent  impairment  of  the  part 
affected,  but  an  apprehension  of  unfavorable  results,  when  it  exists, 
prompts  efforts  to  meet  and  terminate  its  tendency  in  the  parts 
affected.  From  three  of  the  terminations  of  inflammation  serious 
consequences  are  to  be  apprehended.  That  is,  when  it  terminates 
in  the  production  of  pus,  the  form  being  known  as  suppurative 
inflammation,  when  it  terminates  in  an  ulcer,  and  when  the  inflam- 
matory action  is  of  such  destructive  character  as  that  of  gangrenous 
inflammation.  These  conditions  are  to  be  avoided,  if  possible,  in 
the  incipient  stage  of  inflammation.  The  disposition  of  inflamma- 
tion is  to  extend  and  involve  several  tissues. 

1.  By  spreading  along  the  tissues  affected  in  its  continuity,  as,  for 
instance,  along  the  skin,  cellular  or  mucous  membranes. 

2.  Where  it  spreads  by  contiguity  of  tissue,  passing  from  one 
affected  structure  to  an  adjacent  healthy  one.  Thus  we  see  the 
opposite  surface  of  an  inflamed  joint  involved  in  disease  at  opposing 
points. 

3.  Inflammation  extending  to  distant  parts  through  the  medium 
■of  the  hlood,  this  fluid  being  depraved,  and  increasing  in  liability 
to  inflammation  in  other  parts,  as  in  some  of  the  erratic  forms  of 
erysipelas,  or  conveying  pus  to  a  distance,  as  in  phlebitis,  and  thus 
giving  rise  to  numerous  centres  of  inflammation. 

4.  Inflammation  may  be  carried  to  distant  parts  by  metastasis,  or 
•subside  by  resolution. 

As  we  are  limited  to  the  treatment  of  inflammation  with  consti- 
tutional symptoms  of  the  asthenic  and  irritative  type,  careful  modi- 
fication in  agreement  with  the  stamina  of  the  patient  is  required. 
The  local  congestion,  however,  must  be  relieved  in  the  early  stage 
•of  the  inflammation.  If  this  is  but  slight,  a  gentle,  saline  purga- 
tive, and  wet  cloths  at  the  temperature  of  the  body,  applied  to  the 
inflamed  part,  and  the  patient  kept  quiet  for  a  few  days,  serves  to 
afford  relief.  If  not  relieved  in  a  reasonable  time,  a  mild  mercurial 
cathartic  may  be  given,  and  a  lotion  of  a  drachm  of  ext.  belladonna 


370  Orthof^edia. 

diffused  in  a  quart  of  water  should  be  applied  to  the  painful  part  by 
means  of  thick  folds  of  cloth;  or,  in  place  of  belladonna,  a  similar 
preparation  and  quantity  of  stramonium.  This  treatment  usually 
affords  relief  in  cases  of  superficial  inflammation.  Deeper  seated 
inflammation,  and  if  located  in  a  joint,  requires  a  much  more  decided 
treatment;  rest  being  enjoined,  a  brisk  cathartic  of  calomel  and 
scammouy  should  be  given,  and  a  large  sized  plaster  of  cantharides 
applied  from  eight  to  ten  hours  over  the  joint,  the  blister  being 
dressed  with  a  large  poultice  of  linseed  meal,  repeated  every  four 
hours  for  forty-eight  hours.  This  decided  treatment  will  usually 
relieve  the  patient  of  pain  and  tenderness  in  the  affected  joint. 
But  the  patient  being  constitutionally  predisposed,  from  an' asthenic 
condition,  strumous  or  scorbutic,  a  constitutional  course  of  treat- 
ment should  not  be  neglected.  Many,  under  these  circumstances, 
are  in  a  tolerable  state  of  nutrition;  to  such,  an  alterative  tonic,  as 
that  of  hydrarg.  bichlorid.  and  tr.  cinch,  comp.,  two  grains  of  the 
former  to  six  ounces  of  the  latter,  may  be  administered  in  half 
drachm  doses,  to  be  taken  three  times  a  day  for  a  month  or  six 
weeks.  This  usually  serves  to. protect  the  patient  from  future  attacks- 
of  inflammation  of  the  joint.  Neuralgic  pain  in  the  limbs,  after  a 
few  months,  in  many  instances,  alarm  and  annoy  the  patient ;  the 
arsenite  of  potassa  solution  in  doses  of  four  or  five  minims  twice  or 
three  times  a  day  soon  affords  relief. 

In  more  feeble,  attenuated  patients,  after  the  purgation  and  blis- 
tering, cod  liver  oil,  two  drachms  a  day,  may  be  given,  in  divided 
doses,  in  conjunction  with  the  alterative  tonic. 

Cod  liver  oil  is  only  of  service  to  the  patient  when  thoroughly 
digested ;  hence  the  stools  should  be  carefully  examined  to  see  that 
a  portion  or  the  entire  amount  of  the  oil  has  not  passed,  undigested,, 
as  is  often  the  case  when  given  in  large  doses.  It  is  from  the  excess 
of  oil  that  has  passed  undigested  that  injury  may  be  apprehended,, 
the  excess  imposed  upon  the  stomach,  in  time,  impairs  the  digestive 
functions.  In  these  cases  of  feeble  physical  development  and  anae- 
mic appearance,  after  a  course  of  the  alterative  tonic,  the  prepara- 
tions of  iron  may  be  employed,  especially  iron  in  combination  with 
iodine,  as  that  of  the  syr.  ferri  iod.,  or  tr.  ferri  chlor.,  or  the  hypo- 
phosphate,  carefully  observed  as  to  their  influence  upon  the 
patient  —  a  suitable  quantity  being  decided  upon.  These  serve  a 
most  admirable  purpose,  often  greatly  invigorating  the  feeble  child 
to  apparent  good  health.     This  end,  however,  is  only  attained  where 


Tonics  and  their  Effect  upon  the  System.       371 

a  proper  regime  is  positively  enforced  to  an  increase  of  nutrition  in 
■which  direction  the  iron  greatly  tends.  In  cases  where  tlie  iron  is 
inadmissible,  and  so  determined  from  observation,  the  subnitrate  of 
bismuth,  in  from  four  to  five  grain  doses,  three  times  a  day,  greatly 
serves  to  promote  digestion,  and  thus  increases  the  virtue  of  the 
cod  liver  oil. 

In  the  advanced  stage  of  inflammation,  and  in  the  induration  of 
parts  to  the  degree  of  abscess,  the  use  of  mercury  must  be  most 
carefully  prescribed.  In  a  gentle  cathartic,  it  often  times  arrests 
excessive  secretion  from  indurated  tissues,  and  when  in  combination 
with  a  tonic,  in  a  minute  quantity,  it  is  an  invaluable  thereapentic 
agent  in  cachectic  cases.  It  is  not  only  serviceable  in  arresting  the 
further  progress  of  the  disease,  but  especially  in  causing  the  absorp- 
tion of  some  of  the  effusions  that  result  from  it,  and  in  removing 
some  of  the  other  effects  of  the  parts.  It  should  be  given  in  small 
doses  for  a  considerable  length  of  time,  until  the  gams  are  slightly 
affected.  In  many  cases  of  depressed  power,  it  may  be  very  advan- 
tageously conjoined  with  cinchona  or  sarsaparilla.  The  most  useful 
preparations  are  calomel,  in  half  grain  doses,  and  the  iodide  of  mer- 
cury in  the  same  quantity,  or,  if  a  gradual  and  continued  effect  is 
desired,  the  bichloride  of  mei'cury,  in  doses  of  from  a  sixteenth  to 
an  eighth  of  a  grain. 

The  iodide  of  potassium,  as  an  alterative  and  absorbent,  is  of 
great  value  in  some  cases,  especially  in  chronic  inflammation  of  the 
fibrous  and  osseous  tissues  occurring  in  strumous  constitutions,  and 
mainly  in  those  cases  where  mercury  is  inadmissible.  In  cases 
where  mercury  has  been  taken  for  some  time  without  apparent 
benefit,  its  use  has  been  followed  with  the  best  results.  Some  days, 
however,  should  be  allowed  to  elapse  after  the  mercury  is  discon- 
tinued before  the  iodide  is  given,  otherwise  profuse  salivation,  or 
even  sloughing  of  the  gums  is  apt  to  result. 

Cod-liver  oil  is  of  very  great  value  in  the  various  strumous  forms 
of  inflammation  in  debilitated,  emaciated,  cachectic,  and  strumous 
subjects.  In  some  cases  it  is  advantageously  conjoined  with  the 
iodide  of  potassium;  or,  in  angemic  cases,  the  preparations  of  iron, 
the  syr.  ferri  iod.,  being  a  most  valuable  one,  or  the  sulphate,  in 
one-four*:h  of  a  grain  to  one  grain  of  ext.  valerian  in  a  pill,  one 
to  be  taken  every  six  hours  where  there  is  great  nervous  irritability 
and  prostration,  alternated  with  teaspoonful  doses  of  the  fresh, 
unbleached  cod-liver  oil.     That  the  oil  should  be  in  this  condition 


372  OrthopjEdia. 

is  ail  important  consideration ;  as  we  have  observed  the  fresh, 
unbleached  cod-liver  oil  retained  upon  an  irritable  stomach  of  a 
child,  when  the  manipulated  or  prepared  oil  in  like  quantities  had 
been  thrown  off,  from  not  being  as  palatable.  But  there  are  much 
more  serious  objections  to  the  use  of  the  bleached,  or  prejoared  oil, 
from  a  loss  of  its  original  constituents  as  cod-liver  oil.  In  the 
dressing  of  leather,  it  is  well  known  to  the  skilful  mechanic  that 
no  other  fish  or  other  oils  will  serve  him  to  perfect  the  dressing 
•of  a  fine  quality  of  leather.  That  its  effects,  when  thus  used, 
dej)ends  upon  the  same  qualities  that  constitute  it  a  medicine,  we 
do  not  know  nor  are  we  prepared  to  advance  that  idea,  but  it  certainly 
determines  the  fact  that  it  possesses  peculiar  properties  aside  from 
its  simple  character  as  an  oil.  That  these  qualities  may  be  lost 
from  manipulation  may  be  presumed  from  the  fact  that  they  are 
very  readily  neutralized  —  leaving  simply  a  mass  of  ordinary  rancid 
fish  oil.  This  peculiar  quality  of  cod-liver  oil  for  the  dressing  of 
leather  is  thus  spoken  of  by  an  elderly  gentleman  of  our  acquaint- 
ance, in  the  trade  :  "  It  has  been  used  for  the  dressing  of  glove 
leather  for  all  of  a  hundred  years  past,  and  no  substitute  of  equal 
nierit  has  been  found  in  that  time."  It  is  said  to  have  been  used 
from  time  immemorial  in  the  maritime  districts  of  Holland,  Grer- 
many,  and  tlie  nortliern  parts  of  Great  Britain,  as  a  popular 
remedy  for  rheumatism  and  rickets.  It  was  first  brought  to  the 
notice  of  the  medical  profession  in  the  year  1783,  by  Dr.  S.  Percival, 
of  England,  and  was  afterward  referred  to  by  Dr.  Bradsley,  in  his 
hospital  reports,  in  1807  ;  but  gained  little  attention  until  the  pub- 
lication of  a  paper  by  Schenck,  in  1823,  in  Hufeland's  Journal, 
■containing  a  series  of  observations  upon  its  efficacy  in  chronic 
rheumatism,  particularly  sciatica.  After  this  time  its  employment 
was  much  extended  in  Germany  and  other  parts  of  the  Continent 
of  Europe  where  its  claims  Avere  set  forth  as  of  great  value  in  the 
treatment  of  scrofula  and  tuberculosis.  In  1841,  it  was  most  highly 
praised  for  its  medicinal  qualities  by  Dr.  J.  Hughes  Bennett,  Pro- 
fessor in  the  University  of  Edinburgh,  which  praises  were  confirmed 
by  the  ample  experience  of  Dr.  C.  B.  Williams  of  London,  and, 
subsequently,  by  that  of  Dr.  Walshe;  and,  both  in  that  country 
and  in  our  own,  the  use  of  the  oil  extended  rapidly,  until  it  haa 
become  a  universal  remedy  for  all  classes  of  wasting  disease,  such  as 
chronic  debility,  with  impoverished  blood,  and  defective  nutrition 
or   assimilation,   not   connected    with    inflammation    or    improper 


Tonics  and  theib  Effect  upon  the  System.        37::^. 

digestion.  When  in  this  condition,  the  subnitrate  of  bismuth 
serves  an  admirable  purpose  in  promoting  digestion,  or,  the  nitrate 
of  silver  in  one-fourth  or  one-eighth  of  a  grain  doses  given  half  an 
hour  after  taking  the  oil.  The  nitrate  of  silver  conjoined  with 
the  cod-liver  oil  is  a  most  efficient  remedy,  where  there  is  a  tend- 
ency to  chronic  diarrhoea. 

In  this  condition  of  the  patient  we  have  a  low  state  of  the  vital 
forces  and  defective  or  depraved  nutrition,  where  there  is  a  tendency 
to  the  production  — in  various  parts  of  the  body,  sometimes  in  one- 
part  and  then  in  another,  and  in  several  parts  at  once  —  of  a  feeble,, 
obstinate  kind  of  scorbutic  inflammation,  strangely  tending  to  the 
suppurative  and  ulcerative  state  and  indisposed  to  a  spontaneous- 
cure,  which  is  usually  designated  by  writers  as  scrofulous  inflamma- 
tion. In  the  tuberculous  form  we  have  deposits  remaining  in  a 
quiescent  condition,  but  subject  to  irritation  involving  neighboring 
parts,  gradually  softening  and  then  discharged  in  suppurations  and 
ulcerations.  Cod-liver  oil  has  a  most  beneficial  influence  over  the 
system  when  in  this  condition;  generally  controlling  it  in  degree, 
often  arresting  for  a  time,  if  not  determining  a  cure. 

In  the  scorbutic  diathesis,  or  scrofulous  inflammation,  without  the 
tuberculous  condition,  free  from  the  induration  of  parenchymatous 
structure,  the  oil  will  often  efi'ect  complete  cures. 

When  the  system  is  characterized  by  the  tuberculous  dejDOsit,  it 
may  be  improved  by  the  oil ;  but  it  is  the  opinion  of  some  of  our 
experienced  teachers  and  practitioners  in  medicine,  that  the  oil  has- 
no  influence  whatever  over  the  tubercle  when  already  formed,  and 
that  its  regular  course  of  degeneration,  involving  surrounding  tissue, 
cannot  be  arrested.  From  this  view  it  is  obvious  that  the  oil  can 
only  prove  curative  when  employed  either  before  the  tuberculous 
deposit  has  taken  place,  or  when  it  has  occurred  in  situations,  or  in 
quantities,  not  necessarily  destructive  to  life  through  disorganiza- 
tion of  the  tissues  afiected.  Thus,  when  the  tubercles  are  deposited 
in  vital  organs  there  is  scarcely  a  chance  of  safety,  because  of  their 
destructive  influence  when  in  a  state  of  dissolution.  The  reverse- 
may  be  said,  however,  when  deposits  are  made  in  the  external  lym- 
phatic glands,  in  the  subcutaneous  cellular  tissues  and  within  bones; 
there  is  reasonable  hope  of  cure  as  the  parts  are  less  essential  to  life, 
and  the  destructive  influence  can  generally  be  supported  until  the 
disintegration  has  passed  off. 

The  effects  of  cod-liver  oil  are  peculiarly  obvious  in  thesuppura- 


374  Or  thop^dia  . 

tive  and  ulcerative  stage  of  the  affection,  whether  in  the  lymphatic 
glands,  subcutaneous  tissues  or  the  skin  itself  Scrofulous  ulcers 
and  abscesses  of  the  neck,  auxillse,  and  groin,  or  of  the  skin  and  the 
areolar  tissue  in  any  part  of  the  body,  often  rapidly  improve  and 
ultimately  get  well  under  its  use.  Large  and  exhausting  abscesses 
of  the  lower  extremities  which  have  reduced  the  patient  during 
months  of  suppuration  to  the  lowest  condition  of  emaciation  and 
debility  compatible  with  life,  gradually  improve  ;  healthy  granula- 
tions being  presented,  and  the  edges  closing  in  by  tender  skin,  pen- 
cilled with  a  weak  solution  of  nitrate  of  silver,  ten  grains  to  the 
ounce  of  water,  and  for  a  dressing,  fresh  mutton  tallow,  in  prefer- 
ence to  the  rancid  ointments  of  the  shops.  The  s«cretion  being 
thin  and  watery.  Turner's  cerate  serves  a  better  purpose  by  giving 
tone  to  the  rising  granulations,  or,  a  wash  of  acetate  of  lead  and 
sulphate  of  zinc,  two  grains  of  each  to  the  ounce  of  water,  and 
when  the  ulcer  is  irritable,  a  drachm  of  the  wine  of  opium  added 
to  the  lotion.  The  mutton  tallow  containing  a  small  portion  of 
carb.  acid,  should  be  thinly  spi'ead  upon  a  cloth  as  a  covering.  This 
simply  sustains  the  recuperative  tendency  that  the  oil  had  produced. 

During  the  treatment  of  this  class  of  ailments,  scrofulous  ophthal- 
mia presents  in  virulent  form ;  demanding  a  gentle  mercurial  cath- 
artic, and  the  above  described  lotion  applied  to  the  eyes  to  afford 
relief.  The  nitrate  of  silver  may  be  applied  to  any  existing  ulcer 
of  the  cornea  or  other  part  of  the  conjunctival  surface  after  the 
inflammation  has  subsided.  Molasses  dropped  in  the  eye,  or  the 
cod-liver  oil,  greatly  improves  the  ulcerated  cornea. 

Cutaneous  eruptions,  and  even  the  obstinate  lupus  will  yield  to 
the  oil  and  liq.  potass,  arsenitis  in  increasing  doses,  to  as  much  as 
the  stomach  will  bear.  We  have  given,  in  obstinate  cases,  from  ten 
to  fifteen  drops  of  the  latter  at  a  dose,  three  times  a  day,  and  this 
has  been  attended  with  the  most  happy  results. 

In  diseases  of  the  bones  and  joints  there  is,  probably,  no  other 
single  remedy  so  efficacious  as  cod-liver  oil,  conjoined  with  altera- 
tives and  tonics.  In  advanced  swellings  of  the  hip,  knee,  and  other 
joints,  with  or  without  abscess  or  caries.  Though  the  cure  is  often 
protracted,  yet  its  curative  tendency  is  most  satisfactorily  demon- 
strated by  the  fact  of  the  most  extensive  induration  being  healed, 
and  the  patient,  although  very  decrepit,  made  to  enjoy  excellent 
health  ;  and  thus  children  are  enabled  to  follow  some  occupation 
for  self-support,  even  acquiring  considerable  muscular  effort. 


Tonics  asd  their  Effect  upox  the  System.        375 

E 11 1  urge  me  nt  of  the  mesenteric  glands  is  a  most  common  condi- 
tion of  children  laboring  under  disease  of  the  joints,  and  requires 
our  special  attention.  Under  such  circumstances  the  oil  is  not 
admissible  until  the  digestive  functious  are  improved  sufficiently  to 
have  it  well  digested.  As  we  have  before  stated,  the  stomach  must 
be  in  a  condition  to  digest  the  oil,  and  in  limited  quantity,  that  the 
power  of  digestion  may  not  be  overburdened,  which  is  a  most  weak- 
ening influence.  The  subnitrate  of  bismuth  given  in  three  or  four 
grain  doses,  three  times  a  day,  an  hour  after  meals  —  (the  amount 
of  fluids  taken  as  drink  being  limited)  —  will  most  readily  relieve 
this  condition  and  pave  the  way  for  the  exhibition  of  the  oil,  upon 
which  the  patient  will  improve,  when  alternated  with  the  before 
mentioned  tonic  alterative  of  bichloride  of  mercury  and  tinct 
cinchona  in  small  doses. 

Some  cachectic  children  have  considerable  abdominal  distention 
and  hardness,  and,  sometimes,  peritoneal  affections,  enlarged  liver, 
great  emaciation,  pallor  and  debility  which  have  generally  been 
ascribed  to  scrofulous  disease  of  the  mesenteric  glands.  Some  of 
these  cases  yield  quickly  and  most  happily  to  cod-liver  oil  and 
cooperating  treatment,  Avhile  others  are  more  or  less  obstinate,  and 
not  a  few  end  fatally  —  as  some  of  the  cases  are  decidedly  tuber- 
culous. They  enlarge  and  harden  and  are  diffused  throughout  the 
abdomen,  causing  peritoneal  inflammation.  These  are,  in  the  gen- 
eral, incurable,  except,  perhaps,  in  a  few  instances,  in  which  the 
tubercles  —  originally  small  in  amount —  are  discharged  from  ulcera- 
tion, or,  possibly,  undergo  absorption  from  degeneration ;  as  children 
under  an  enforced  regime  will  recover  from  all  the  indications  of  a 
tuberculous  diathesis.  These  affections  of  the  liver  and  mesenteric 
glands  are,  in  some  cases,  simply  of  an  inflammatory  character,  and 
terminate  favorably  under  skilful  treatment. 

Diarrhcea,  with  ulceration  of  the  bowels,  is  not  an  unfrequent 
attendant  on  bone  or  joint  disease.  This  sometimes  depends  upon 
tubercles  in  the  bowels,  leaving  ulcers  as  they  are  discharged  ;  in 
other  instances,  it  has  been  found  to  be  connected  with  tubercles. 
Scorbutic  or  scrofulous  inflammation,  without  tubercles,  when  it 
attacks,  exclusively,  the  mucous  membrane,  showing,  when  it  does 
so,  a  tendency  to  affect  the  follicles,  and  to  result  in  ulceration  of 
these  structures.  The  gastric  mucous  membrane  may  be  invaded 
as  well  as  the  intestinal.  In  these  cases,  the  nitrate  of  silver  in 
one-fourth  of  a  grain  doses,  given  at  an  interval  of  an  hour  before 


376  Orthop^^dia. 

or  after  taking  food,  three  times  a  day,  and  a  teaspoonful  of  cod-, 
liver  oil  half  an  hour  after.  These  are  the  remedies  we  most 
approve  of ;  the  cuticle  being  excited  with  the  flesh  brush,  after  cold 
sponging,  once  a  day  when  about  to  retire  for  the  night. 

Chronic  inflammation  of  the  nostrils,  or  ozaena,  chronic  angina, 
and  chronic  laryngitis  and  bronchitis  are  all  ailments  that  present 
in  patients  laboring  under  joint  diseases,  and  yield  tardily,  but 
finally,  to  the  use  of  cod-liver  oil  and  alterative  tonics. 

EiCKETS,  being  a  disease,  the  result  of  impaired  digestion,  indi- 
cated by  the  light  colored  stools,  capricious  appetite  —  often  vora- 
cious —  is  most  readily  relieved  by  the  subnitrate  of  bismuth, 
tinct.  cinchona,  and  hydrarg.  bichlorid.  This  relief  appears, 
however,  to  be  only  an  arrest  of  the  impairment  of  the  digestive 
functions,  and  the  cure  is  rendered  more  permanent  by  the  use  of 
cod-liver  oil,  which  creates  a  most  remarkable  change  toward 
improvement  in  the  child's  appearance  ;  the  enlarged  joints  assume 
normal  form,  and  the  sallow  skin  becomes  clear  and  healthy  in 
appearance. 

It  has  been  recommended  to  employ  the  oil  externally,  by  fric- 
tion, and  most  highly  recommended  for  its  constitutional  impression 
upon  children  when  administered  in  this  form  —  the  stomach  being 
in  a  very  irritable  condition  —  and  it  may  be  worthy  of  a  trial.  Our 
practice  has  been  not  to  attempt  to  give  the  oil  before  having  allayed 
the  irritability  of  the  stomach  and  prepared  the  digestive  organs  for 
its  proper  digestion.  In  cases  of  irritable  stomach  it  may  prove 
beneficial  from  external  application  in  the  commencement  of  treat- 
ment, and  thus  limit  the  preparatory  course  tending  to  its  assimila- 
tion when  taken  into  the  system,  and  worthy  of  favorable  consider- 
ation in  the  treatment  of  patients,  thus  delicately  conditioned 

SElfSIBLE   PEOPERTIES    OE   COD   LIVER   OIL. 

In  constitution  cod  liver  oil  is  similar  to  ordinary  fish  oil.  In  its 
purest  form  it  is  of  a  color  varying  from  a  slightest  tint  of  trans- 
parent yellow  to  a  fine  golden  yellow;  when  less  pure,  of  a  light 
brown  color,  but  still  transparent;  when  most  impure,  dark  brown 
and  opaque  in  mass,  though  transparent  in  thin  layers.  Its  odor 
and  taste  are  quite  peculiar,  scarcely  disagreeable  in  the  finer  kinds, 
but  offensive  in  the  most  impure,  and  also  somewhat  acrid.  The 
oil  is  injured  by  long  exposure  to  the  air.  It  contains  a  peculiar 
principle  called  gaduin.  not  known  to  have  any  medicinal  virtue, 


Tonics  and  their  Bffect  upon  the  System.       S7Y 

various  biliary  principles,  a  little  iodine  and  iromine,  olein  and  mar- 
garin,  and  many  other  constituents  of  no  special  interest.  Its  most 
obvious  characteristic  properties  are  its  odor  and  taste  —  quite  dif- 
ferent from  that  of  ordinary  fish  oils  —  with  which  every  practitioner 
should  become  familiar  so  as  to  be  ^ble  to  determine  the  pure  from 
the  adulterated  oil ;  for  adulteration  of  this  article  has  become  a 
very  common  practice.  The  odor  strongly  resembles  that  of  shoe 
leather  which  owes  its  fineness  of  finish  to  the  cod-liver  oil  used  in 
its  preparation.  Another  distinctive  property  derived  from  its  biliary 
constituents,  is  that  of  assuming  fine  colors,  or  changes  of  colors, 
under  the  action  of  the  mineral  acids. 

There  has  been,  as  yet,  no  substitute  discovered  that  equals  in 
medicinal  properties  the  cod -liver  oil.  In  Bennett's  Practice  of 
Medicine,  page  184,  we  find  the  following  impressive  remarks  upon 
this  most  valuable  medicine  :  "  Our  present  knowledge  has  led  to  a 
complete  revolution  in  our  practice.  Thus,  moderate  exercise  to 
stimulate  respiration,  cold  sponging,  nutritious  diet,  and  a  bracing 
system  has  been  found  more  beneficial ;  at  the  same  time  avoiding 
anodynes  and  cough  mixtures,  which,  by  diminishing  the  appetite 
and  inducing  weakness,  interfere  with  nutrition.  Indeed,  it  has 
been  proved  that  the  best  methods  of  lessening  cough  expectoration, 
and  sweating,  are  the  means  which  produce  increase  of  general 
strength;  so  that  if  we  can  carry  out  the  general  indications,  the 
local  symptoms  may  be  safely  left  to  themselves. 

''In  doing  thiswe  have  now  the  advantage  of  possessing  a  remedy 
which,  in  cases  of  tuberculosis,  is  of  the  highest  nutritive  import- 
ance, as  it  gives  to  the  system  that  fatty  element  in  which  it  is  so 
defective,  and  in  a  form  that  is  more  easily  assimilated,  and  more 
capable  of  adding  to  the  molecular  elements  of  the  body  than  any 
other.    I  allude  to  Cod-liver  Oil. 

"And  now,  you  cannot  fail  to  perceive  how  the  molecular  doctrine 
of  organization  and  of  growth,  not  only  explains  the  known  facts 
in  physiology  and  pathology,  but  constitutes  the  basis  for  a  true 
therapeutics.  Fatty  particles,  as  we  have  seen,  form  the  molecular 
fluid  of  chyle,  while  out  of  chyle  blood,  and  through  it,  all  the  tissues 
are  formed.  Impairment  of  digestion  in  scrofula  and  tuberculosis 
renders  chylification  imperfect;  the  fatty  constituents  of  food  are  not 
separated  from  it  and  assimilated ;  the  blood  consequently  abounds 
in  albuminous  elements,  and  when  exuded  forms,  as  we  have  seen, 
tubercles.     To  induce  health  it  is  necessary  to  restore  nutritive 


378  OrthopjEDIa. 

elements  which  are  diminished,  and  that  is  done  directly  by  adding 
a  pure  animal  oil  to  the  food.  While  an  informatory  exudation  in 
previously  healthy  persons  should  be  treated  by  supporting  the  vital 
powers  generally,  so  as  to  permit  its  molecules  going  through  the 
transformation  necessary  for  their  growth  and  elimination,  in  tub- 
erculosis we  add  the  constituent  of  food  necessary  for  the  formation 
of  the  molecules  themselves.  By  so  doing,  we  form  good  chyle  and 
blood,  we  restore  the  balance  of  nutrition  which  has  been  disturbed; 
respiration  again  active  in  the  excretion  of  carbonic  acid  gas ;  the 
tissues  are  more  nourished  from  the  blood,  the  elements  so  necessary 
for  their  sustenance.  The  entire  economy  is  renovated,  so  that 
while  the  histogenetic  processes  are  renewed,  the  hystolitic  in  the 
tubercle  itself  also  are  stimulated,  and  the  whole  disappears." 

This  is  a  very  ingeniously  devised  theory,  and  acceptable  to  our 
experience  as  to  the  modus  operandi  of  cod  liver  oil  —  a  medicine 
tending  to  the  restoration  of  normal  activity  or  progressive  increase 
of  vital  energy  in  the  animal  economy,  the  very  ultima  thule  of 
attainment  in  the  treatment  of  chronic  disease. 


INDEX. 


Page. 

Abbe's  (Dr.  Rob't)  case  of  Dupuytren's  contraction  of  the  fingers 173 

Abdomen,  relaxed 244 

Abdominal  hernia — its  varieties 212 

do       '       its  causes 213 

do             symptoms  of 214 

do             divisions  of  the  various 215 

do             diagnosis 217 

do              construction  and  application  of  trusses  for  relief  of 230 

Aberration  of  form,  tendencies  to 46 

Abnormal  position  of  bones,  ligaments,  and  mutcles  in  talipes  varus 44 

Absorption,  promotion  of 130 

Accumulating,  static  electricity,  machine  for 116 

Action,  alterative 129 

sedative 129 

Adams'  (Mr.  Wm.)  method  of  operating  for  Dupuytren's  contraction  of  the 

fingers 173 

Anchylosis,  in  its  various  conditions 323 

treatment  of 330 

Ancient  treatment  of  deformity  27 

Ancient  treatment  of  spinal  deformities 30 

Adventurous  treatment,  paralysis  the  result  of. , 110 

Air,  pure,  as  a  tonic 363 

Alterative  action  of  electricity 129 

Amenorrhoea 142 

Aneurisms 143 

Anterio-posterior  curvature,  treatment  of 200 

Apparatus,  Dr.  Jerome  Kidder's  electrical 167 

Appliances,  mechanical 348 

Applying  electricity,  modes  of 145 

Aponeurosis,  contraction  of  the  plantar 80 

Arrangement  of  galvano-caustic  battery  and  parts 163 

Arteries,  treatment  of  punctured 59 

Bartlett's  regulator 161 

Batteries,  portable  galvanic 157 

Battery,  cabinet  regulator  and 160 

the  galvano-caustic 163 

Bones,  abnormal  position  of 44 


380  Index. 

Page. 

Bull  (Dr.  "Wm.  T.),  operative  treatment  for  genu-valgum 210 

Bursae 255 

treatment  of 257 

Cabinet  regulator  and  battery 160 

Calcaneus,  talipes 86 

cause  of  talipes 87 

treatment  of  congenital  talipes 87 

do               non-congenital  talipes 88 

Capillary  circulation 131 

Caries  of  the  cervical  vertebrae 342 

Caries  of  the  vertebrae 385 

do                 diagnosis 336 

Caries  of  the  last  cervical  and  first  dorsal  vertebrae 109 

spine,  treatment  of 344 

cervical  vertebrae 342 

Cartilages,  floating,  in  joints 334 

Cases  demanding  tenotomy 105 

Cases,  prognosis  of  unfavorable 305 

Causes  of  talipes  valgus  and  condition  of  the  bones 72 

talipes  equinus 82,  85 

talipes  calcaneus 87 

necrosis 315 

Caustic,  galvano-battery,  preparation  of 163 

do              electrodes 165 

do              arrangement  of  battery  and  parts 163 

Cautery,  galvano 166 

Chronic  inflammation,  treatment  of 365 

Circulation,  capillary 131 

Cod-liver  oil,  sensible  properties  of 376 

Com]iression  of  the  spinal  cord  in  Pott's  Disease,  a  case  of 272 

Concussion,  electric , 123 

Condition  of  the  muscles  in  talipes  varu? 50 

of  the  bones  in  talipes  valgus 72 

pathological,  tending  to  lateral  curvature 184 

Conformation  of  the  foot 42 

Congenital  luxation 25 

Congenital  talipes  calcaneus,  treatment  of 87 

Congestion,  use  of  electricity  in  132 

Conservative  surgery  as  practiced  in  the  Hospital  for  the  Ruptured  and 

Crippled 276 

Constipation  a  cause  of  hemorrhoids 247 

Construction  and  application  of  trusses  for  the  relief  of  abdominal  hernia. . .  230 

Contraction,  organic 133 

of  hands,  fingers  and  toes 168 

of  the  plantar  aponeurosis 80 

of  the  fingers,  operative  treatment  for 171 

do             splints  to  be  used  after  operation 173 


Index.  381 

Page. 

Contorted  feet,  surgical  treatment  of. 52 

do        preparatory  steps  in  treatment  of 53 

Contortions,  impairment  of  tissues  resulting  in 39 

of  the  foot,  various  forms  of 41 

resulting  from  paralj'sis 52 

the  sequence  of  infantile  paralysis 92 

special  treatment  of,  the  sequence  of  infantile  para  ysis 101 

and  ulceration  of  the  toes 174 

spastic,  and  their  treatment 179 

Coulson  (Wm.),  on  joint  disease  in  the  scrofulous  diathesis 262 

Counter-irritation 132 

Coxarius,  morbus 283 

do           special  treatment  of 298 

Cure,  means  of,  in  first  stage  of  talipes  varus 65 

tenotomy  as  a  means  of 192 

Current,  silent , 122 

Curvature,  congenital  lateral,  of  the  spine 181 

non-congenital,  of  the  spine 182 

do                 do           diagnosis  of 186 

do                 do           treatment  of 188 

pathological  condition  tending  to  lateral 184 

treatment  of  anterio-posterior 200 

of  the  spine,  kyphosis,  or  posterior 338 

Defective  physical  formation 9 

Deformities,  ancient  treatment  of  spinal 30 

Deformity,  ancient  treatment  of 27 

surgical  means  of  redressing 32 

Diagnosis,  electrical 128 

of  lateral  curvature  of  the  spioe 186 

of  caries  of  the  vertebrae  336 

of  the  various  abdominal  hernia 217 

Digestion  and  menstruation,  influence  of  electricity  in 131 

Diseases  of  sheaths  of  tendons 258 

do  do  treatment  of 259 

of  the  joint?,  pathological  consideration  of 278 

Divisions  of  the  various  abdominal  hernia 215 

Division  of  the  sterno-cleido-mastoideus  muscle 195 

Dr.  Jerome  Kidder's  electrical  apparatus 167 

Dr.  Knight's  modification  of  Scarpa's  shoe,    and  mode  of  applying  it  in 

talipes  varus 66 

Dyscrasia,  constitutional,  etiology  of 261 

Ectropion  vesicae 243 

Ertorts,  personal,  in  primary  treatment 108 

Electrical  apparatus.  Dr.  Jerome  Kidder's 167 

Electrical  induction 125 

diagnosis 128 

influence 129 


382  Index. 

Page. 
Electrical  rubefacient 125 

sedative  influence 125 

as  a  tlierapeutic  agent  in  treatment  of  paralysis 121 

alterative  action 12& 

as  a  counter-irritant 132 

improved  Holtz  machine 118 

concussion 125 

revulsion 132 

shock 123 

sparks. . 123 

generators  of  galvanic 155 

machine  for  accumulating  static lift 

modes  of  applying 145 

promotion  of  nutrition  by 130 

do         secretion  by 130 

do        absorption  by 130 

results  of  static. : 134 

reactive  power  of 12& 

sedative  action 120 

use  of,  in  capillary  circulation 131 

digestion  and  menstruation 131 

inflammation 131 

congestion 132 

vitalizing  power  of 128 

Electrodes,  galvano-caustic 165 

Electro-magnetic  machine,  portable 15ft 

Equinus  talipes 78 

do  causes  of 82 

do  treatment  of 83 

do  from  various  causes 85 

Exercise,  muscular. 133. 

Exhilarating  influence  as  a  tonic 362 

Extorsium,  genu 204 

do  treatment  of 206 

Extreme  cases  of  Talipes  Valgus,  treatment  of 75 

Fascia,  severing  the  plantar 55 

Feet,  various  forms  of  contortion  of  the 41 

surgical  treatment  of  contorted 52 

preparatory  steps  in  treatment  of  contorted 53- 

Femoral  heroia,  truss  for  the  relief  of  reducible 230 

Fingers,  contraction  of  the 168 

First  dorsal  vertebras,  paralysis  the  result  of  caries  of 109- 

Flexum,  posterior  genu 112 

Floating  cartilages  in  joints 334 

Foot,  conformation  of  the 42: 

means  of  restoring  the,  to  normal  form 54 

Form,  tendencies  to  aberration  of 4ft 

Formation,  defective  physif^al ^ 


Index.  383 

Page. 

Galvanic  batteries,  portable. 157 

electricity,  generators  of 155 

Galvano-caustic  battery,  the 163 

do                     preparation  of 1C3 

do                     electrodes 165 

Galvano-cautery 166 

Ganglion,  diseases  of  sheaths  of  tendons . . 258 

do                                 do             treatment  of 259 

Generators  of  galvanic  electricity 155 

General  remarks  on  the  treatment  of  talipes 62 

Genu  extorsium 20i 

do            treatment  of 206 

Genu  flexum,  posterior 112 

Genu  valgum 208 

do           treatment  of 209 

do                   do          in  advanced  cases 210 

Hands,  contraction  of  the 168 

Hemorrhoids  ...    246 

Hernia 212 

abdominal,  its  varieties 212 

its  causes 213 

its  symptoms 214 

construction  and  application  of  trusses  for  the  relief  of. . .  230 

complicated  with  a  retained  testicle 219 

diagnosis  of 217 

divisions  of  the  various 215 

prognosis  of  the  ailment 220 

truss  for  the  relief  of  reducible  inguinal  and  femoral 235 

Impairment  of  tissues  resulting  in  contortions 39 

Induction,  electrical 125 

Infantile  paralysis 91 

do  contortions  the  sequence  of 92 

do  prognosis  in 95 

do  special  treatment  of  contortion,  the  sequence  of 101 

Inflammation,  use  of  electricity  in 131 

treatment  of  chronic 365 

Influence,  electrical 129 

exhilarating,  as  a  tonic 362 

Influence  ol  ligaments  in  talipes  varus 51 

of  occupation  tending  to  paralysis  and  the  treatment 115 

Inguinal  hernia,  truss  for  relief  of  reduciljle 235 

Introductory  remarks 1 

Jerome  Kidder's  (Dr.)  electrical  apparatus 167 

Joints,  pathological  consideration  of  diseases  of  the 278 

floating  cartilages  in 334 

Joint,  synovitis  of  the  knee 318 


384  Index. 

Page. 

Kidder's  (Dr.  Jerome)  electrical  apparatus 167 

Knight's  (Dr.)  moditication  of  Scarpa's  shoe,  and  mode  of  applying  it  in  talipes 

varus 66 

Knives,  tenotomy 60 

Kyphosis,  or  posterior  curvature  of  the  spine  338 

Last  cervical  vertebrae,  paralysis  the  result  of  caries  of 109 

Lateral  curvature  of  the  spine,  congenital 181 

do                 do                 non-congenital 182 

do                  do                  diagnosis  of 186 

do                 do                  treatment  of 188 

do                  do                  pathological  condition  tending  to 184 

Ligaments,  abnormal  position  of,  in  talipes  varus 44 

influence  of,  in  talipes  varus 51 

Luxation,  congenital 25 

Machine  for  accumulating  static  electricity 116 

Magnetic,  portable  electro,   machine 156 

Maligna,  onychia 177 

Means  of  redressing  deformity,  surgical 32 

of  restoring  the  foot  to  normal  form 54 

of  cure  in  first  stage  of  talipes  varus 65 

of  cure,  tenotomy  as  a 192 

Mechanical  appliances 348 

Menstruation,  eflect  of  electricity  on 131 

Moditication  of  Scarpa's  shoe  (Dr.  Knight's) 66 

Morbus  coxarius 283 

Muscles,  abnormal  position  of,  m  talipes  varus 50 

division  of  the  sterno-cleido-mastoideus 195 

Muscular  exercise,  use  oi  electricity  in 133 

Necrosis,  causes  of 315 

Non-congenital  talipes  calcaneus,  treatment  of 88 

do             lateral  curvature  of  ihe  spine 182 

Nutrition,  promotion  of,  by  electricity. 130 

Occupations,  influence  of,  tending  to  paralysis,  and  their  treatment 115 

Oil,  cod  liver,  sensible  properties  ot 376 

Onychia  Maligna 177 

Organic  contraction 133 

Paralysis,  contortion  resulting  from 52 

infantile 91 

prognosis  in  infantile 95 

the  sequence  oi  unrelieved 96 

special  treaimeni  of  contortion,  the  sequence  of  infantile 101 

the  result  ol  caries  of  the  lasi  cervical  and  first  dorsal  vertebrae. .  109 

the  result  ol  adventurous  treatment. 110 

electricity  as  a  therapeutic  a^ent  ui  the  treatment  of 121 

Pathological  condition  tending  to  lateral  curvature 184 

do                 of  diseases  01  the  joints 278 


Index.  385 

Page. 

Personal  efforts  in  primary  treatment 108 

Plij'sical  formation,  defective 9 

Plantar  fascia,  severing  the 55 

Plantar  aponeurosis,  contraction  of  the 80 

Portable  electro-magnetic  machine 156 

galvanic  batteries 157 

Posterior  genu  flexum 112 

curvature  of  the  spine 338 

tibial  tendon,  severing  the 57 

Power— reactive,  in  electricity 129 

vitalizing,  in  electricity 128 

Preparatory  steps  in  treatment  of  contorted  feet 53 

Preparation  of  galvano-caustic  battery 163 

Primary  treatment,  personal  efforts  in 108 

Procidentia  uteri 237 

do              treatment  of 239 

Projecting  sternum 201 

do              treatment  of 202 

Prognosis  of  hernia 220 

do           unfavorable  cases  of  morbus  coxarius 305 

Properties,  sensible,  of  cod  liver  oil 376 

Punctured  arteries,  treatment  of 59 

Pure  air  as  a  tonic 363 

Eachitis 197 

Eeactive  power  of  electricity 129 

Redressing  deformity,  surgical  means  of 32 

Reducible  inguinal  and  femoral  hernia 235 

Regulator,  Bartlett's 161 

cabinet  and  battery 160 

Kelaxed  abdomen , 244 

Remarks,  general,  on  treatment  of  talipes 62 

introductory 1 

Revulsion,  electrical 132 

Rubefacient,  electrical 125 

Scarpa's  shoe,  Dr.  Knight's  modification  of,  and  mode  of  applying  it  in 

talipes  varus 66 

Scorbutic  diathesis,  severity  of  symptoms  of  joint  disease  in 262 

susceptibility  of  cure  of  joint  disease  in 270 

symptoms  of , 262 

illustrative  case  of 263 

Second  stage  of  talipes  varus  and  treatment 68 

Secretion,  promotion  of,  by  the  use  of  electricity 130 

Sedative  action 129 

Sedative  intluence  of  electricity 125 

Sensible  properties  of  cod  liver  oil 376 

Severing  the  plantar  fascia 65 

the  posterior  tibial  tendon 57 


386  Index. 

Page. 

Sheaths  of  tendons  (Ganglion),  diseases  of , 258 

Shock,  electric 123 

Sparks,  electric 123 

Spastic  contortions  and  their  treatment 179 

Special  treatment  of  contortion  the  sequence  of  infantile  paralysis 101 

Special  treatment  of  morbus  coxarius 298 

Spinal  cord,  a  case  of  compression  of,  in  Pott's  disease 272 

Spine,  congenital  lateral  curvature  of  the l 181 

non-congenital  lateral  curvature  of  the 182 

non-congenital  lateral  curvature  of  the,  diagnosis  of 186 

pathological  condition,  tending  to  lateral  curvature 184 

treatment  of  lateral  curvature 188 

treatment  of  caries  of  the 344 

Static  electricity,  machine  for  accumulating 116 

do  results  of 134, 118 

Statistics  of  2,943  cases  of  hip  disease 277 

Sterno-cleido-mastoideus  muscle,  division  of  the 195 

Sternum  projecting 201 

do                treatment  of 202 

Struma,  two  conditions  of 262 

Strumous  diathesis,  absence  of  pain  in  joint  lesions  of 263 

a  case  illustrative  of  joint  disease  in 270 

Surgical  means  of  redressing  deformity 32 

treatment  of  contorted  feet 52 

Symptoms  of  abdominal  hernia 214 

Synovitis  of  the  knee  joint 318 

System,  tonics  and  their  effects  upon  the 359 

Tables  and  statistics  of  5,461  cases  of  joint  disease  treated 273 

Tahpes  calcaneus 86 

do              causes  of 87 

do              treatment  of  congenital 87 

do              treatment  of  non-congenital 88 

Talipes  equinus 78 

do            cause  of 82 

do           treatment  of 83 

do           from  various  causes 85 

Talipes  valgus — causes  and  condition  of  the  bones 72- 

do             treatment  of 73 

do             extreme  cases  of 75 

do             improved  apparatus  for  treatment  of 89 

Talipes  varus,  abnormal  position  of  bones,  ligaments  and  muscles  in 50 

do          the  condition  of  the  muscles  in 50 

do          influence  of  ligaments  in 51 

do          second  stage  of,  and  treatment 68 

do  third  stage  of 57,  71 

do           general  remarks  on  treatment  of 62 

do          means  of  cure  in  the  first  stage  of 65 


Index.  387 

Page. 
Talipes  varus,  Dr.  Knight's  mode  of  applying  his  modification  of  Scarpa's 

shoe  in 66 

Taxis 222 

Temperature  as  a  tonic 364 

Tendencies  to  aberration  of  form 46 

Tendons,  diseases  of  sheaths  of 258 

do  treatment 259 

severing  the  posterior  tibial 57 

Tenotom  J'  knives 60 

cases  demanding 105 

as  a  means  of  cure 192 

Testicle,  retained,  complicated  with  hernia 219 

prognosis  of 220 

Tibial  tendon,  severing  the  posterior 57 

Tissues,  impairment  of,  resulting  in  contortions 39 

Toes,  contraction  of  the 168 

contortion  and  ulceration  of  the 174 

Tonic,  exhilarating  influence  as  a 362 

pure  air  as  a 363 

temperature  as  a 364 

Tonics,  selection  and  qualities  of 359 

and  their  effects  upon  the  system 359 

Torticollis,  treatment  of 194 

Treatment  of  anchylosis  in  its  various  conditions M'A 

of  anterio-posterior  curvature 200 

of  bursse 257 

of  caries  of  the  spine 344 

of  chronic  inflammation 365 

of  contorted  feet,  preparatory  steps  in 53 

of  congenital  talipes  calcaneus 87 

of  deformity,  ancient , 27 

of  diseases  of  sheaths  of  tendons 259 

of  genu  extorsium 206 

of  genu  valgum 209 

of  lateral  curvature  of  the  spine 188 

and  means  of  cure  in  the  first  stage  of  talipes  varus 65 

special,  of  morbus  coxarius 298 

of  non-congenital  talipes  calcaneus 88 

of  diseases  in  occupations  tending  to  paralysis 115 

of  paralysis,  the  result  of  adventurous 110 

of  paralysis,  electricity  as  a  therapeutic  agent  in 121 

of  procidentia  uteri 239 

of  projecting  sternum 202 

of  punctured  arteries  , 59 

of  spinal  deformities,  ancient 30 

surgical,  of  contorted  feet 52 

of  talipes,  general  remarks  on  the 62 

of  talipes  equinus 8S 


388  Index. 

Page, 

Treatment  of  talipes  valgus 73 

do             extreme  cases 75 

in  second  stage  of  talipes  varus 68 

of  third  stage  of  talipes  varus ... . . 71 

of  torticollis 194 

of  varicose  ulcer 252 

Truss  for  relief  of  abdominal  hernia,  constructioji  and  application.   230 

reducible  inguinal  and  femoral  hernia 235 

Tumors,  use  of  electricity  in  regard  to 142 

Ulcer,  varicose 251 

treatment  of. 252 

Unfavorable  cases,  prognosis  of 305 

Use  of  electricity  in  capillary  circulation 131 

in  congestion 132 

in  digestion  and  menstruation 131 

in  inflammation 131 

in  muscular  exercise 1S3 

in  promotion  of  nutrition 130 

do              secretion 130 

do              absorption 130 

Uteri  procidentia 237 

treatment  of 239 

Valgum,  genu,  treatment  of , 209 

Valgus,  talipes,  causes  of,  and  condition  of  the  bones 72 

treatment  of 73 

extreme  cases  of 75 

Varicose  veins 248 

ulcer 251 

treatment  of. 252 

Various  forms  of  contortion  of  the  feet 41 

Varus,  condition  of  muscles  in  talipes 50 

abnormal  position  of  bones,  ligaments  and  muscles  in  talipes 51 

first  stage  of  talipes 65 

second  stage  of  talipes 68 

third  stage  of  talipes ,   57,  71 

Vertebra,  caries  of  the 335 

do             diagnosis  of 336 

do             cervical 342 

last  cervical  and  first  dorsal,  paralysis  the  result  of  caries  of 109 

Vesica,  ectropion 243 

Vesication  as  a  derivative  in  hip  disease 266 

Vitalizing  power  of  electricity ' 128 


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